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7 



GENERAL PATHOLOGY. 



:- 



ELEMENTS 



GENERAL PATHOLOGY: 



PRACTICAL TREATISE 



CAUSES, FOEMS, SYMPTOMS, AND RESULTS OF DISEASE. 



BY ALFRED STILLE, M.D. 

LECTURER ON PATHOLOGY AND THE PRACTICE OP MEDICINE ; MEMBER OP THE 

MEDICAL SOCIETY OP OBSERVATION, OP PARIS ; FELLOW OP THE 

PHILADELPHIA COLLEGE OF PHYSICIANS, ETC. 



Ratiocinationem igitur plurimum laudo, siquidem ex fortuita occasione ducat. 
Quod si non ex evjdenti occasione, verum ex probabili rationis fictione ducatur. 
plaerunque graven* et molestam infer! affectionem. 

Hippocrates. 




PHILADELPHIA: 
LINDSAY AND BLAKISTON, 

z!848. 



Entered, according to the Act of Congress, in the year 1848, 

By Lindsay and Blakiston, 

In the Clerk's Office of the District Court for the Eastern District of 
Pennsylvania. 



C. SHERMAN, PRINTER, 
19 St. James Street. 



TO 

WILLIAM W. GERHARD, M.D, 

WITH RESPECT 

FOR HIS IMPORTANT CONTRIBUTIONS TO PATHOLOGY, 

WITH ADMIRATION 

FOR HIS EMINENCE AS A PHYSICIAN AND A TEACHER, 

AND WITH GRATITUDE 

FOR THE SOUND DOCTRINE OF HIS PERSONAL INSTRUCTION, 

AND THE EXAMPLE OF HIS INDUSTRY AND ZEAL, 

£bis iDork 

IS AFFECTIONATELY INSCRIBED 
BY HIS FRIEND AND EARLIEST PUPIL. 



PREFACE. 



English Medical Literature has hitherto possessed no work ex- 
clusively devoted to General Pathology. In nearly all of the sys- 
tematic treatises and dictionaries of medicine in our language this 
subject is either discussed theoretically and imperfectly, or is alto- 
gether unnoticed. The well-known and valuable work of Dr. 
Williams forms scarcely an exception to this statement, for its 
scope not only embraces General Pathology in the proper sense, 
but also hygiene, prophylaxis, and therapeutics ; in consequence of 
which extended plan the author was obliged to restrict himself to 
" a brief general view of Etiology, Nosology, Semeiology, Dia- 
gnosis, and Prognosis," subjects which will be found to occupy 
•nearly the whole of the following pages. 

It is hoped that the attempt now made to supply the deficiency 
which is thus disclosed in our medical literature will not be 
thought untimely, and that the difficulties inseparable from such a 
task, will secure for the writer the candid criticism of his profes- 
sional brethren. He is convinced that among the most serious 
defects in the present system of medical education, are an almost 
total neglect of logical analysis, and a tendency, where generali- 
zation is at all encouraged, to speculate on fanciful analogies, 
rather than to extract truth from facts. How fatal these influ- 
ences must be to a successful study of disease, and to that confi- 






Vlll PREFACE. 

dence in medicine which experience imparts to the philosophical 
physician, is too apparent to require illustration. The author is 
persuaded that the view of medical science which it is the pro- 
vince of General Pathology to afford, is eminently adapted to 
correct these evils, by encouraging a more healthful discipline, 
and infusing a more hopeful spirit, among those who are preparing 
for medical practice. 

Defects like those complained of are nearly if not quite as 
palpable in the education of English physicians, whose writings 
but too often afford evidences of their existence. The eminent 
teacher alluded to above, fully confirms this opinion in the follow- 
ing words, which are respectfully commended to the meditation 
of American physicians : " I venture to affirm, that a chief reason 
why the practice of medicine has been commonly so distasteful, 
and so difficult in its study, and so unsatisfactory when tested at 
the bedside, is, because its foundation, general pathology , has not 
been efficiently taught." 

An intimation was given in the original announcement of the 
publishers of this work, that it was to be prepared with reference to 
the Elemens de Pathologie Generate of M. Chomel. On reflec- 
tion, this plan was speedily abandoned by the author, who pre- 
ferred employing as a basis for the work the Lectures delivered 
by him in a medical institution of this city. He has the less reason 
to regret this decision, since there has just appeared in Boston, a 
translation of M. ChomePs treatise, by Dr. F. E. Oliver, and Dr. 
W. W. Morland. The lectures referred to have merely served as a 
nucleus, around which have been arranged much more abundant 
materials, derived from all of the best sources accessible to the 
author. The works named in the subjoined list, besides those 
mentioned in the text, have been faithfully consulted and freely 
employed. The most valuable assistance was rendered by that of 



PREFACE. IX 

MM. Hardy and Behier, which is the most complete, as well as 
the* most recent, work on General Pathology. 

While acknowledging his obligations to various sources for the 
materials of his work, the author takes the liberty of mentioning 
his indebtedness to his brother, Dr. Moreton Stille, for important 
services rendered in preparing his manuscript for the press. 

Philadelphia, March 3d, 1848. 



LIST OF THE PRINCIPAL WORKS CONSULTED. 



Prosper Alpinus. — The Presages of Life and Death in Diseases ; 
translated from the Latin by R. James, M. D. ; 2 vols. Lon- 
don, 1746. 

Van Swieten, Commentaries upon Boerhaave's Aphorisms. Trans- 
lated from the Latin ; 18 vols. Edinburgh, 1776. 

Zimmerman, Traite de PExperience en general, et en particulier 
dans Part de guerir. Traduit de PAUemand, par Lefebvre- 
de Villebrune. Paris, 1774. 

Gaubius, The Institutions of Medicinal Pathology. Translated by 
Erskine. Edinburgh, 1778. 

Double, Semeiologie Generale, ou Traite des Signes et de leur 
valeur dans les Maladies ; 3 vol. Paris, 1811-22. 

Landre Beauvais, Semeiologie, ou Traite des Signes des Maladies, 
3eme ed. Paris, 1818. 

Rostan, Traite elementaire de Diagnostic, de Pronostic, de- 
dications Therapeutiques, ou Cours de Medecine Clinique ; 3 
vol. Paris, 1826. 

Vulpes, Istituzioni di Patologia Generale; 2nda ed., 2 vol. In 
Napoli, 1830. 

Dubois (d' Amiens) Traite de Pathologie Generale, 2eme edition. 
Bruxelles, 1835. 

Piorry, Traite de Diagnostic et de Semeiologie, 3 vol. Paris, 
1S37. 



Xll LIST OF WORKS CONSULTED. 

Raciborski, Precis pratique et raisonne du Diagnostic. Paris, 
1837. 

Schill, Outlines of Pathological Semeiology. Translated from the 
German, by D. Spillan, M. D. Republished, Philad., 1841. 

Chomel, Elemens de Pathologie Generate, 3eme ed. Paris, 1841. 

Williams, Principles of Medicine : comprising General Pathology 
and Therapeutics, and a brief general view of Etiology, No- 
sology, Semeiology, Diagnosis, and Prognosis. Republished, 
Philada., 1844. 

Requin, Elemens de Pathologie Medicale; 2 vol. Paris, 1843. 

A. Hardy and J. Behier, Traite elementaire, &c. Pathologie Ge- 
nerale et Semeiologie. Paris, 1844. 

Copland, A Dictionary of Practical Medicine ; Art. Disease, 
causes of, &c. American edition, by Dr. Lee. New York, 
1846. 

Vogel, The Pathological Anatomy of the Human Body. Trans- 
lated from the German, by George E. Day, M. A., &c. 
London, 1847* 



TABLE OF CONTENTS. 



PAGE 

Preface, ..-...-- v. 

Introductory Essay, Medical Truth : its nature, sources, and means 

of attainment, - - - - - - -25 



PART I. 

^ETIOLOGY. 

CHAPTER I. 

PRELIMINARY OBSERVATIONS. 

Pathology divided into general and special ; objects of the former and 
method of treating it — General notion and definition of disease — 
Nomenclature of diseases, - - - - - 50 



CHAPTER II. 



ETIOLOGY PROPER. 



Section I. — Cause defined — Classification and description of causes, - 60 

II. — General predisposing causes, .... 64 

III. — Special predisposing causes, - - . - 73 
2 



C N T R N T! 



CHAPTER III, 



EXCITING CAUSES. 



Section I. — General and special exciting causes, - - 88 

II. — The specific causes of disease, - ... 94 



PART II. 

THE GENERAL PHENOMENA, THEORY, AND CLASSIFICATION OF 
DISEASES GENERAL DIAGNOSIS AND PROGNOSIS. 

CHAPTER I. 

THE TYPE, DURATION, STAGES, TERMINATIONS , AND SEAT OF DISEASE. 

Section I. — Of the type or form of disease, - > 114 

II. — Of the duration of diseases, - . 116 

III. — Of the stages of disease, - - - - - 118 

IV. — Of the terminations of disease, - - - - 123 

V. — Of the seat of diseases, ..... 142 

CHAPTER II. 

PATHOGENESIS, OR THE THEORY OF DISEASE. - . 150 

CHAPTER 111. 

GENERAL NOSOLOGY, - « . 158 

CHAPTER IV. 

DIAGNOSIS, - - - 162 

Section I. — The qualifications of a medical observer, - - . 163 

II. — The mode of investigating a case of disease, - - 167 

III. — The mode of recording and generalizing medical cases, - 175 

IV. — Modes of physical examination, - - - 177 



CO N TENTS. XV 

CHAPTER V. 

PROGNOSIS, - 200 

PART III. 

SEMEIOLOGY, 

Symptoms and signs defined — Varieties of symptoms — Value of 

semeiology, - - - - - - .213 

CHAPTER I. 

SIGNS FROM THE EXTERIOR OF THE BODY, 217 

Section I.- — The position and size of the body — Colour, temperature, 

&c, of the surface, - - - - - 218 

II. — Signs from the head, face, and neck, - 239 

III. — Signs from the exterior of the trunk, » 248 

CHAPTER II. 

SIGNS FROM THE DIGESTIVE APPARATUS, - . 256 

CHAPTER III. 

SIGNS FROM THE GENITO-URINARY AITARATUS, - 274 

CHAPTER IV. 

SIGNS FROM THE NERVOUS SYSTEM. 

Section I. — Signs from the function of sensibility, - . . 290 

II. — Signs from the organs of voluntary motion, - - 301 

III. — Signs from the intellectual functions, - . . 308 

CHAPTER V. 

SIGNS FROM THE CIRCULATORY APPARATUS, - - 314 



XVI CONTENTS. 



CHAPTER VI. 



SIGNS FROM THE RESPIRATORY APPARATUS. 

Section I. — The so-called rational signs of pulmonary disease ; includ- 
ing the respiration, dyspnoea, cough, the sputa, &c, - 364 
II. — Physical signs in diseases of the respiratory apparatus, 379 



PART IV. 

GENERAL MORBID ANATOMY. 

CHAPTER I. 

THE ORIGIN, PROGRESS, AND VALUE OF MORBID ANATOMY, - 404 

CHAPTER II. 

THE METHOD OF CONDUCTING POST-MORTEM EXAMINATIONS, - 412 

CHAPTER III. 

OF THE CHANGES PRODUCED BY DISEASE IN THE NORMAL CONSTITUENTS OF THE 

BODY. 

Section I. — Of the blood in disease, ..... 418 

II. — Inflammation, ...... 434 

III. — Altered nutrition, ...... 440 

CHAPTER IV. 

NEW FORMATIONS, - - . 456 

CHAPTER V. 

MORBID PRODUCTS NOT INCLUDED IN THE PRECEDING CLASSIFICATION, 468 



INTRODUCTOKY ESSAY. 



MEDICAL TRUTH. 

ITS NATURE, SOURCES, AND MEANS OF ATTAINMENT. 

General Pathology presents an almost boundless field for 
study. All branches of medical science and of medical literature, 
are, to some extent, included within it, because they furnish the 
materials out of which it is formed. Whoever, therefore, attempts 
its investigation is obliged to select, from the topics it presents, 
such as he is capable of grasping ; and must apply to them such 
principles of reasoning as the peculiarities of his mind and educa- 
tion have rendered natural and familiar. 

In common with most authors, the writer of the present treatise 
proposes to set the truth before his readers, but conscious that this 
phrase represents no medical doctrine received of all men, but only 
" that which every man thinketh," he makes bold to claim indul- 
gence while endeavouring to expound his interpretation of medical 
truth. 

Truth, which is an exact accordance with fact or reality, has no 
absolute existence except in the Creator of the universe, because no 
finite mind can stand in any conscious relation to all created things. 
Revealed truth is an expression of the Creator's will, and so far as 
it extends, is perfect, and, like its author, unchangeable. But me- 
dical truth is neither absolute nor revealed. Intuitive truth is that 
which carries conviction with itself; it has only to be stated to be 
admitted. Of this sort is the consciousness a man has of his own 
existence, a conviction which no reasoning can either strengthen 
or invalidate. It is this which gives sacredness to Genius. No 
man can seize all the relations of the moral and physical world, 

3 



26 INTRODUCTORY ESSAY. 

but some few possess the power of instinctively perceiving and 
elucidating moral truths. Such truths, and so discovered, are 
those which have been sung by the poet and taught by the moralist 
in all ages, and whose real accordance with the principles of human 
nature is shown by the fact that they are essentially the same, 
wherever promulgated. But medical truth is not intuitive. Again, 
there is demonstrative truth. Mathematical propositions are of 
this sort. They repose on axioms and postulates, which cannot 
be gainsaid, and which are, therefore, absolute and immutable. 
The conclusions at which they furnish the means of arriving are 
consequently certain. But it is to be observed that the elements 
of mathematics are mere abstractions. There is really no such 
thing as a straight line, a plane surface, a regular curve, a perfect 
sphere, a uniform solid, as defined by the geometrician. Hence 
it is that mathematical propositions in the abstract, pure mathema- 
tics, are rigorously true; but in practice, applied mathematics, are 
liable to all the errors created by defective senses, and imperfect 
instruments, errors which can only be corrected by observation 
and experience. Medical truth is not demonstrative. These seve- 
ral kinds of truth are intellectual chiefly ; they have their origin 
in the mind ; they are evolved, weighed, and applied by the men- 
tal faculties. But there remains another and a very different one. 
This is inductive truth. It is that which belongs to the physical 
sciences, which is the sacred element of all (so called) natural 
laws ; the search after which is the life-spirit of astronomy, of 
chemistry, geology, and medicine, whose progress has been rapid 
while it was active, and slow when it declined. It is that very 
truth which is " the daughter of time, and not of authority," and 
which alone can outlive the waste of ages, and man's contempt and 
neglect. Its origin is not in the mind, but in external nature. Ob- 
servation is the great instrument for its discovery, and next, experi- 
ment, which is observation under circumstances of our own choos- 
ing. Facts are its materials, co-ordinated facts contain its laws. 
The ancients were ignorant of it, or had but a faint perception of 
its power. They preferred to speculate and dogmatize rather than 
study the interpretation of nature. Their ambition was to form a 
sect and captivate public opinion ; to triumph over their opponents 



MEDICAL TRUTH. 27 

rather than to prove themselves possessed of truth ; to sharpen 
their wits rather than to exercise and improve their senses. Hence 
the barrennessofthe ancientphilosophy,its utter unproductiveness of 
anything really useful to mankind. Well did it deserve the sentence 
pronounced upon it by its greatest judge. " It is not wonderful," 
says Lord Bacon, " that the Egyptians (who bestowed divinity and 
sacred honours on the authors of new inventions) should have con- 
secrated more images of brutes than of men ; for the brutes by their 
natural instinct made many discoveries, whilst men made few from 
discussion and the conclusions of reason." If modern times have 
any advantage over antiquity, it certainly is not either in acuteness 
or force of reasoning, (which are of all ages and may be made to 
support a bad as well as a good cause,) but in that knowledge 
which has flowed from long and repeated observation. The theo- 
ries which ruled the world successively, have disappeared one after 
another, like succeeding fashions in equipage and dress, while many 
of the facts recorded two centuries before the Christian era, recur 
in the daily walks of our profession, precisely as the Father of 
medicine inscribed them on his tablets. The Galenical theory, 
that of Paracelsus, of Borelli, of Van Helmont, of Silvius, all 
world-renowned in their day and generation, are now less honoured 
than the scattered dust of their inventors. No other destiny awaits 
the hypotheses which have more recently arisen and flourished. 
Brownism and Rushism, Broussaisism and Hahnemannism, with 
all the other fruits of a luxuriant fancy and a poverty of facts, must 
descend the inevitable slope to oblivion ; but the vast collection of 
truths established by the observation of nature, are as immutable 
as herself. 

It is not asserted that the originators of medical systems were 
wholly ignorant or regardless of observation, or that such physi- 
cians as Hippocrates, Celsus, Aretceus, Sydenham, Baglivi, and 
Morgagni, were entirely free from the shackles of speculation. But 
while the latter exerted all their industry and talent in collecting and 
pondering facts, caring little for the establishment of one doctrine 
rather than another, the former, by dint of medilation and subtle 
reasoning, elaborated from a few facts such complete and ingeni- 
ous systems, that they were afterwards ashamed to descend to the 



28 



INTRODUCTORY ESSAY. 



gross and mechanical process of observing, and by degrees be- 
came so charmed with their own work, as to hold for certain what 
they had at first regarded as only probable. Since the days of 
Hoffman and Boerhaave, a little more than a century ago, even 
the most hardy theorists have professed to base their systems upon 
facts. Technical logic and metaphysical reasoning have been al- 
most discarded from the schools, and no one now claims accept- 
ance for his doctrine, upon the ground of any internal evidence of 
its truth, but simply on that of its conformity to the results of ob- 
servation. Such is the spirit of the age. The reigning philosophy 
has almost always shaped medical theories. While the former oc- 
cupied itself with unsubstantial shadows, the latter were subtle and 
flimsy, — mere cobwebs of the brain. But when the old philosophy 
began to totter under the sturdy blows of Lord Bacon, and was 
completely overthrown by the Sceptics of the last century, Aristo- 
tle and Galen were abandoned to the dust and the worm, and Na- 
ture began to be worshipped in their stead. The consequences of 
this revolution have been stupendous. The physical sciences, one 
and all, have revived, and in a few years advanced far on the road 
to perfection. But not content with narrow limits, they have taken 
under their fostering care the mechanical arts, infusing into them 
a vigour, and communicating to them an impulse which have re- 
acted upon every human interest, social, political, and religious. 
Less than half a century has sufficed for this work, for changing 
the whole of Christendom from speculative to practical, and for ren- 
dering this, (what it is so often called,) the mechanical age. If the 
natural sciences were once crushed under the incubus of metaphy- 
sical and theological disquisitions, or etherialized by the refined 
and poetical tastes of our ancestors, they have already been avenged. 
They have driven from amongst us nearly all of true faith, of en- 
nobling and generous poetry, of single-hearted devotion. It is the 
misfortune of humanity ever to run into extremes, to adopt a pre- 
scriptive policy, to lose sight of that portion of good which mingles 
with, and redeems from condemnation, even the most imperfect 
things. If the. ideal once supplanted the natural, does it follow, 
that when nature triumphs, the imagination must be chained in the 
dust? By no means; for each has its appropriate sphere. The 



MEDICAL TRUTH. 29 

poet should hold undisputed sway in his own realm, the scientific in- 
vestigator reign supreme in his. Thev cannot wield a common and 

cor " 

united sceptre, for the subjects of the one are airy nothings, — people 
of the land of dreams, that rise at any moment, or in any shape that 
their master wills. Those of the other are the works of nature, 
which exist by no power of his, which change or pass away with- 
out his interposition, of which he is merely the spectator, and which 
he thinks his life well employed, if he can, at last, learn to inter- 
pret. 

It cannot be kept too constantly in view, that there is no neces- 
sary connexion between medical and intuitive truth, between the 
physical sciences and poetry or religion. To assert such a con- 
nexion, is to pervert or degrade them all ; to arrest the progress of 
human improvement, and to arm the unbeliever with the most fatal 
weapons. The literary world has, of late years, been deluged with 
treatises and declamations on the poetical and religious tendencies 
of science, and especially on the persuasives to religion furnished 
by medical investigations. All this is essentially erroneous, and 
indicates a complete misconception of the nature of truth, and an 
ignorance of the different kinds of evidence required by different 
truths. 

One of the most ingenious and sublime conceptions of astrono- 
mical science, — the Nebular Hypothesis, — one which has inspired 
much ardent and elevated devotion, and been the theme of much im- 
passioned admiration, was invented by the great Laplace, — not be- 
cause he had exalted notions of the power and wisdom of God, or 
was impressed with a sense of his own and this world's insignifi- 
cance, in the midst of that infinite number of systems and worlds 
with which immensity is filled, but, as he himself avowed, " to do 
away with the necessity of a Creator" Now, the religious, or rather 
anti-religious conclusion which he drew from the contemplation of 
natural phenomena, was precisely the opposite of that which other 
men, no less acute, inferred from the same premises. Both parties 
could not possibly be right, and yet neither could convict the other 
of a logical error. The paradox is explicable by the fact, that La- 
place was an infidel before, as well as after his great invention, 
while those whose conclusions were opposed to his, were Chris- 



30 INTRODUCTORY ESSAY. 

tians. The two parties saw the same object through different me- 
dia, and therefore saw it differently. If an impartial umpire could 
have been found, he would, probably, have given judgment against 
both parties, declaring that the facts in question were scientific 
facts, — that they had nothing to do with religion, and, of them- 
selves, gave as little countenance to the blasphemy of the one, as 
to the enthusiasm of the other. 

It is common for persons to imagine that the study of astronomy 
must be delightful; that it must purify and elevate the soul, and 
inspire it with sublime conceptions of the Creator of all things. 
With these laudable sentiments, they open an astronomical trea- 
tise, and find a sad array of ellipses, parabolse, tangents, paral- 
laxes, equations of curves, and other algebraic formulae, which have 
no more to do with the visible or metaphysical relations of the 
heavenly bodies, than have the letters of the alphabet with the ob- 
jects they are employed to name. The poetico-religious inquirer 
closes the book in disappointment, and reproaches astronomy for 
not teaching him what it never professed to teach, — what, indeed, 
it was incapable of teaching. He should have blamed himself for 
not having taken the pains to inquire how that science was to be 
studied, — what were its legitimate objects, and its appropriate 
sphere. The same remarks are true of the other sciences, and, to 
their full extent, of medicine. Whoever would cultivate it with 
pleasure and profit, must first inform himself thoroughly of its na- 
ture, capabilities, and aim ; for, if he do not, one of two conse- 
quences will inevitably ensue : either he will fail to accomplish any- 
thing honourable or useful, let him labour never so assiduously, or 
he will, sooner or later, abandon the profession in disgust, per- 
suaded that he has been deceived. He will have found that, in- 
stead of filling him with veneration of the wonderful contrivances 
of the human organism, and inspiring him with poetical or devo- 
tional feelings, it rather tended to diminish his faith, to materialize 
his speculations, to blunt his sensibilities ; that instead of his find- 
ing in it exhaust less mines of metaphysical research, of gaining 
from it any light as to the cause of life, the nature of vitality, the 
connexion of the soul and body, it not only left him as ignorant of 
these things as ever, but taught him that they were unattainable, 



MEDICAL T8U T H. 31 

and endeavoured to narrow down his inquiries to mere objects of 
sense. If this has really happened to any one, the fault was his 
own. Before entering upon medical studies, he should have fully 
comprehended their nature, learned how they ought to be prose- 
cuted, and what advantages might fairly be expected from them. 
From this error the writer would preserve his readers ; he would 
convince them that the science of medicine is founded alone upon 
the observation of facts, to the entire exclusion of all hypothetical 
reasoning, and that, as a science, it has as little to do with the ima- 
gination or the conscience, as has the determination of a comet's 
orbit with the " Music of the Spheres." 

It was stated that all the natural sciences are built up and per- 
fected by observation ; but the results of observation are not equally 
exact in all. This is owing to the character of the elements of 
which they are composed. In proportion as these are simple and 
determinate, will the results be accurate. In astronomy, which is 
concerned with vast masses, bearing but few and constant relations 
to one another, mathematical calculations are easily applied, and 
the few general laws of the science readily deduced. Hence it is 
that astronomers are able to predict the occurrence of an eclipse, 
or the return of a comet to a given point in space, with as much 
certainty as the rising of the morrow's sun. If an error is com- 
mitted in a particular case, the fault is in the observer, or in the 
imperfection of the instruments employed by him, but not in the 
irregularity of the phenomena observed, nor in the principle on 
which the investigation proceeded. In inorganic chemistry, the 
elements are more numerous, the instruments less perfect, the prin- 
ciples less certain. In its study, therefore, errors are still more 
inevitable. In organic chemistry, again, the difficulties are mul- 
tiplied ; besides all of those which belong to its sister department, 
others, which are the result of life, abound, and substances of iden- 
tical chemical composition no longer display the same, nor even 
similar physical properties. Advancing to physiology, we find the 
uncertainty augmented. Effects are there witnessed which cannot 
be arranged under any known chemical or mechanical laws, but 
are sometimes apparently in contravention of such laws. In phy- 
siology, we have to deal not only with matter, but with organized 



32 INTRODUCTORY ESSAY. 

matter; not only with organized, but with living matter; not only 
with living matter, but with a living soul, in its thousand reac- 
tions with the body, which are, for the most part, not only un- 
known, but wholly incomprehensible. If, then, so much doubt 
and obscurity envelope our knowledge of physiology — of the nor- 
mal and natural state of the human economy — how much thicker 
darkness must involve our notions of its abnormal conditions or 
diseases? If we add to all these difficulties, inherent in the sub- 
ject itself, and which there is little hope of removing, those which 
ignorance, fancy, prejudice, and wilful deceit have added, — the 
false facts of medicine, as they have been called, — medical truth 
will appear to be shut up in a fortress, impregnable by human 
wisdom or human industry. 

This is a discouraging and disheartening statement; one which 
would seem to admit, that medicine deserves all the sarcasms and 
ridicule which have been heaped upon it by the ignorant ; that it 
is unworthy of the name of science, and scarcely deserves to be 
called an art. But, after all, what does this avowal amount to? 
Merely that medical knowledge is neither perfect in itself, nor easy 
of acquisition. Is it, therefore, to be condemned, and buried in the 
same tomb with alchemy and astrology ? Or are not its very im- 
perfections the rather to be studied, that they may be removed? 
For let it be remembered, that disease exists ; and, in one form or 
another, medical art has existed from the beginning, and must en- 
dure just so long as man's physical nature continues to be what it 
has always been. We are not called upon nor permitted to decide 
whether medicine shall be abandoned ; we can only choose be- 
tween cultivating it seriously and ardently, and paying it a luke- 
warm and enforced respect. 

The very uncertainty of medicine, if rightly understood, is one 
of the most effectual spurs to industry. It keeps benevolence 
warm; it makes us anxious and observant; it excites our ambition 
to rank with those who have most largely contributed to the re- 
sources and the progress of medicine. It is undeniable, moreover, 
that this progress is real ; that built upon the foundation already 
described, our scientific edifice is yearly rising in more stately and 



MEDICAL TRUTH. 33 

elegant proportions, from amidst the rubbish accumulated around 
it by the lapse of time. 

Allusion has been made to the false facts of medicine. Their 
sources are various, but are principally these : wilful impos- 
ture, and self-deception resulting from a too ardent tempera- 
ment, or from trusting in a preconceived hypothesis. Of the for- 
mer are the numberless expedients of charlatanism, both within 
the profession and external to it ; the claims to important discove- 
ries, and to the performance of cures in cases well known to be 
irremediable, or to a much larger success than is either probable, 
or proved by subsequent experience, or to the easy removal of dis- 
eases which the most honest and skilful practitioners admit to be 
very obstinate, if not incurable. These things, it is true, deceive 
none but the ignorant, and the progress of science cannot be long 
retarded by such small impediments. It meets with far more 
serious obstacles in some of its most zealous friends, in those 
who, by the inadequate study and rapid generalization of a few 
facts, proclaim new and wonderful results which are accepted as 
so many truths, upon the strength of their author's well-known ve- 
racity, and the assurance of their being the legitimate offspring of 
observation and experience. 

Having now endeavoured to show that observation is the only 
instrument by which the physical sciences, and medicine amongst 
them, can either be created or perfected, and that false and imper- 
fect observation forms the greatest obstacle to their improvement, 
it remains to be inquired what are the principles and the method 
of true observation in medicine. 

The primary object of all medical investigation is, to distinguish 
diseases from one another. It is evident that all discussions about 
any disease, are utterly futile, so long as it is not agreed in what 
it differs from all other diseases. That there are various diseases, 
results from the most trivial and vulgar observation. The records 
of medicine in their most imperfect state, recognise the same fact, and 
it is employed as the very foundation of every treatise upon medical 
art. Consequently, in proportion as observation is minute and accu- 
rate, will each disease be exactly defined and separated from others 
which have a greater or less resemblance to it. Thus, formerly it 



34 INTRODUOTOF Y ESS AY. 

was not considered possible to distinguish pleurisy from pneumo- 
nia ; but a more rigorous investigation employed in later times, 
enables us to diagnosticate these affections with almost absolute 
certainty. Formerly there were united under the common name 
of inflammation of the brain, what are now known to be distinct 
affections ; under the name of cardiac palpitations, diseases as 
widely different as organic and functional alterations: so, too, of 
continued fevers, and other affections. The power now possessed of 
discriminating between maladies which were once confounded, to 
the great injury of the science and all rational therapeutics, has 
been entirely conferred by a system of close and methodical obser- 
vation, by series of cases reduced to writing, and analyzed, as 
nearly as possible, with mathematical rigour. It is affirmed, that 
the results already obtained are to be regarded, not as absolute and 
final, but only as provisional ; not as the best possible, but only as 
the best for the time being. The correctness of the method is alone 
asserted to be positive, and beyond dispute. 

Most of the writers whose names have been mentioned as con- 
nected with the real progress of medicine, seem to have adopted 
this plan to a certain extent, and none more fully than the Father 
of Medicine himself. But he, as well as all his successors, until very 
recently, preferred to communicate the general results, rather than 
the elements of their experience, in the form of aphorisms, or short, 
pithy maxims, which were easily remembered by their pupils. 
These aphorisms were what might be called the general impies- 
sions left upon the minds of physicians by the whole course of their 
experience. There is no evidence of their having been formed by 
any more rigorous process, and consequently, many of them have 
long since been shown to be unequivocally false, and many others 
are expressed so obscurely, as to have little practical value. The 
cases which have come down to us from the older writers, are, for 
the most part, such as are least valuable, the rare, namely, the cu- 
rious, and the anomalous. It became necessary, therefore, that the 
moderns should apply themselves to the natural history of disease, 
and build up the science anew, from its very foundations, by slow 
and gradual labour. Thus it is, that nearly the whole domain of 
pathology, such as we now possess it, is of very recent acquisition, 



MEDICAL TRUTH. 35 

ind in spite of their declamation against it, is used habitually, and 
valued by the very persons who insist that we have added nothing 
o ancient medicine, and who decry and ridicule the mechanical 
abour of observation. They consider the collection and observa- 
ion of facts as among " the slow processes of a vulgar intellect," 
ind would have truth seized by " the vigorous sallies of specula- 
te genius ;" but they fail entirely to show a single medical 
ruth which was ever revealed by means of their favourite method. 

Bacon says of the necessity of recording experience : " The under- 
standing is as incapable of acting on such materials with the aid of 
nemory alone, as any person would be of retaining and achieving 
3y memory, the computation of an almanac. We cannot approve 
)f any mode of discovery without writing, and when that comes 
i?ito general use, we have further hopes. . . . We shall then 
3e able," he continues, " to put the forces of the understanding in 
lue order and array, by 'means of proper and well-arranged, and, 
is it were, living tables of discovery of those matters which are 
lhe subject of investigation, and the mind can then apply itself 
to the ready prepared and digested aid which such tables afford.'''' 

It is somewhat remarkable, that although these precepts were 
promulgated more than two hundred years ago, and many physi- 
cians since that time have professed to guide their inquiries by the 
Baconian philosophy, yet not until within twenty or thirty years 
has any one carried them into literal execution. It is hardly less 
remarkable, that the first to practise and teach successfully this 
method, was not one of that nation so justly proud of their great Lord 
Chancellor, but of that other people which has ever been their rival, 
and often their victor, in science, arts, and arms. If Bacon did 
not think it humiliating to man's intellect to employ this method in 
the pursuit of truth, we can well afford to feel unscathed by the 
"sallies of speculative genius" directed against it. He well knew, 
and declared with emphasis, that it gives to industry and honesty 
a large advantage over all speculation, however ingenious, and 
that, to use his own words, " it levels mens' wits, and leaves little 
to their superiority, since it achieves every thing by the most cer- 
tain rules and demonstrations." 

Upon the same subject, Baglivi says, " The whole history 



36 INTRODUCTORY ESSAY. 

of diseases depends upon a diligent and patient description of 
all such things as the learned observer has marked down con- 
cerning their invasion, progress, and issue, and committed to 
writing with the same simplicity and sincerity that he used 
in observing them, without adding anything of his own." The 
authority of Stoll's writings cannot be wondered at, when his plan 
of observation is known. " I shall," he says, " minutely detail 
the history of my patients, so that if my reasoning should cause 
any one to err, my observations cannot have that effect, because 
they are faithful and exact transcripts of the truth. I shall relate 
them, not from memory , on which little dependence can be placed, 
but out of my case book, for whose accuracy the numerous and 
daily attendants on the hospital can vouch." Heberden's high 
rank in medicine was gained by similar means. He tells us that 
the notes on which his Commentaries are based, were taken in the 
chambers of the sick, from themselves or their attendants. 

The celebrated Bordeu has well expressed the same idea. " It 
would be well," says he, " if every one were obliged to produce 
the written proofs of his observations, since we too readily adopt 
the opinions of others, and nothing is easier than self-deception. 
We remember what was favourable to our views, and forget the 
rest. The observer, or he who is able to furnish well-recorded 
cases, must not be satisfied with saying, I have seen, I have done, 
such a thing, for your mere stone-blind observers may say as 
much ; he must sustain his assertions by written proofs which will 
show that he really did see, and knew that he saw at a given time. 
He must be ready to convince even a sceptic, who may say to him, 
Pray, where did you observe? how did you observe? and, what is 
of still more consequence, what right had you to observe? what 
precautions did you take against deception ? what proofs have you 
that you were not deceived ?" 

Additional citations might be made from other authors, but these 
suffice to show that the principle for which we are contending has 
long been recognised, as well by those who made an imperfect use 
of it, as by those who can hardly be said to have employed it at 
all. We may then, without further argument at present, regard 
it as proven, that written and detailed narratives of individual cases 



MEDICAL TRUTH. 37 

constitute the only sufficient materials for composing the history of 
any particular disease. 

Admitting, then, that every correct history of a disease, and all 
satisfactory precepts for its management, must be drawn from a 
series of well-observed cases of the disease, not confided to the 
memory, merely, but preserved in writing; it may now be asked, 
by what process the result in question may be obtained ? 

Let it be supposed that when the Asiatic cholera first made its 
appearance in this country, our physicians had had no knowledge 
of it, either from reading or report. A case, the first case, occurs. 
The medical attendant of the patient is surprised at the novelty of 
the symptoms, and is at a loss how to oppose them. However, he 
prescribes, and the patient recovers. Soon afterwards he is called 
to another person affected very nearly like the first. He cannot 
help perceiving that he has again to do with the same disease ; 
and, as a matter of course, he employs his original prescription. 
But the patient dies. A third person sends for him, attacked in 
nearly the same manner as the two others. What reflections does 
the physician make, instinctively. " Here," he observes to him- 
self, " is the same disease ; the prominent symptoms are precisely 
like those I have witnessed in the other cases. That much is 
settled. But, is the patient in danger? I have seen one die and 
one recover," he replies, "therefore the chances in the present case 
are equal, so far as it is possible for me to judge. But what treat- 
ment shall I employ? Again the same doubt; I have at least as 
good reason to resort to my first plan, as to reject it ; the whole 
experience I have in regard to it amounts to this, that in one case 
where it was used the patient recovered, that in another similar 
case he died. The success may have been owing to my remedies, 
the failure may have been in spite of them, certainly was not be- 
cause of them ; I am bound, therefore, to try them again." They are 
once more prescribed, and the patient gets well. At this point our 
physician is met by a brother practitioner, who begs to be informed 
about this new and extraordinary disease. He may receive an 
answer framed in one or the other of the following styles. " I 
have seen a number of cases of this new affection ; in some, the 
onset was sudden, in others gradual ; in all of them there were 






38 INTRO IjUCTORY ESSAY. 

vomitings, cramps, violent diarrhoea, with rice-water discharges ; 
suppression of the urine, blueness of the skin ; in some there was 
reaction after collapse, in others none. I employed such and such 
remedies, and have reason to be satisfied with them, for I have 
only lost one patient. The disease is certainly a very serious one, 
but I have cured more cases than I have lost." Or, " I have seen 
three cases of the disease, all of them in persons between the ages 
of 20 and 40, day labourers, and previously in perfect health. 
One of the three died, the other two recovered. In the fatal case, 
the onset was sudden, beginning with a chill, soon followed by 
vomiting and purging; in both of the other cases, the attack came 
on gradually, and was preceded by uneasiness, headache, sleep- 
lessness, loss of appetite, &c. It was about twenty-four hours 
before these patients fell into the same condition as the first was 
in from the beginning ; then the symptoms of all three became 
alike ; there was vomiting, every five or ten minutes, of such and 
such matters, and stools at the same intervals ; but, subsequently, 
without intermission, of such and such fluids, amounting to half a 
gallon or more in the hour. The pulse, in the fatal case, was im- 
perceptible from the start ; in the other cases it was small, quick, 
and beat about 90 per minute, until the collapse approached, when 
it rose to 120, 130, and at last could not be counted. The col- 
lapse was nearly the same in all three of the cases ; its symptoms 
were so and so ; in the fatal case, however, it terminated in death 
in six hours from the commencement ; in the other two, (at the end 
of three hours, in one case, and four in the other,) the discharges, 
coldness, blueness, &c, diminished, and were followed by fever. 
In one of the cases, this lasted only about thirty-six hours, and 
ushered in full convalescence; in the other, the fever assumed a 
typhoid form, with such and such symptoms, which were not en- 
tirely dissipated until the 12th day from the commencement of 
the attack, when the patient slowly regained his strength. The 
number of my cases is, of course, too small to afford a complete 
picture of this disease ; but it is the best my materials allow me to 
give. This is still truer of the treatment, for having no idea of 
what the mortality of the disease would be if left to itself, I cannot 
presume to say that my treatment had any influence on the results 






31 E DIC A L TRUTH. 39 

I have obtained. I have adopted it owing to the remote analogy 
of the present affection with some other diseases familiar to mo ; 
but experience only can determine its fitness. When T shall have 
had one or two hundred cases under my charge, the results of my 
observation will possess a more definite value." 

It will be readily understood from this illustration, that if the 
object of the inquirer was to learn all that he could about the cho- 
lera, the latter of the two answers to his question, could alone 
supply the information he was in search of, because it was a faith- 
ful narrative of what his informer had really observed, and was 
conveyed in language as exact as possible, while the first answer, 
although not absolutely false, was yet not strictly true, was an un- 
faithful representation of what had occurred, and led to, if it did 
not admit, false conclusions, for it was evasive, indefinite, and in- 
complete. The second answer was faithful, because it described 
minutely what had actually been seen and felt, and in terms ad- 
mitting of no double construction. If a quantity was to be ex- 
pressed, it was expressed in numbers ; the ages of the patients, the 
duration of the several stages of the disease, the frequency of the 
pulse, the intervals of vomiting and purging, and the amount of 
matters rejected, were all capable of being represented by figures, 
and had, therefore, a claim to be so rendered, as the most, and in- 
deed the only precise method possible. 

It may seem strange, that there should be different opinions 
on such a point as this ; that men should be found not only 
to question the utility of describing cases of disease with such 
rigorous nicety, but even to ridicule and deride the efforts of 
those who are labouring to introduce exactness into medicine, 
and to characterize them as dull and uninspired plodders, with- 
out the elevation or the enthusiasm of genius. Surely, if know- 
ledge is valuable, it is only so in proportion to its accuracy ; 
to deny this, would be to admit the absurdity, that nothing is 
worthy of being thoroughly known. Every one knows that gold 
is heavier than water ; but is such knowledge to be compared 
to that of the man who can tell us that gold is 19*25 heavier than 
water? We all know that the pulse of an infant is more fre- 
quent than that of an adult; but have we no obligations to him 
who informs us that the average rate of the former is about 95 per 



40 INTRODUCTORY ESSAY. 

minute, and of the latter about 75 ? We may be acquainted with 
the fact, that the fibrinous element of the blood is increased in in- 
flammatory affections ; but does he not deserve our thanks who 
proves, that although the normal proportion of this constituent is 
but 3 parts in 1000 of the blood, yet in the class of diseases men- 
tioned, it is increased to 5, 7, 8, or even 10 parts in the 1000? 

In the illustration presented a few moments ago, it was, we trust, 
made apparent, that the second answer attributed to our physician, 
was the only one that could be given in conformity with the strict 
demands of science. It was, at the same time, admitted, in conse- 
quence of the paucity of facts on which it was founded, to be insuf- 
ficient for determining anything very certainly about the disease 
to which it referred. But if the same kind of note had been taken 
of one, two, or five hundred cases of the same malady, no argu- 
ment is needed to show that deductions fairly made from them 
would have a much higher value than those drawn from the origi- 
nal three cases ; for this is no more than to say what every one 
admits, that experience is valuable. It is equally clear that if all 
these were cases of persons about the same age, of the same sex, 
condition, health, and submitted to the same treatment, a general 
abstract of them would present a perfect picture of the disease as 
it affected that sort of persons, and we might fairly conclude that 
another equal number observed under the same circumstances 
would furnish nearly identical results : — for the operations of nature 
are uniform in disease, as elsewhere, and like causes must produce 
like effects. 

In drawing out a general description of the disease we could 
proceed in one way, and in one only, if we meant to be accurate. 
Having two hundred cases and desiring to know the mortality 
amongst them we should easily obtain it by counting; desiring to 
learn how far cramps are to be considered a symptom of the cho- 
lera, we should have but to search through the whole series of 
cases, when perhaps it appears that 190 patients had this symp- 
tom, while in 10 it was absent, which result ought to be given in as 
many words, or the statement made that the symptom was nearly 
constant; desiring to know the average duration of the disease, we 
add together the periods of all the cases, and divide the sum by the 



MEDICAL TRUTH. 41 

number of cases; we may make this calculation separately for the 
fatal cases, and for those which recovered ; or we may find, in a 
similar way, the maximum and minimum duration of the malady. 
And so in regard to all of the symptoms, and their various relations. 
If we would discover the anatomical character of the disease, we 
have only to count the lesions mentioned in our records, and to put 
those of each organ by themselves, by which means we presently 
come to the conclusion that such or such an alteration of structure 
existed in every case, that certain others were present in a majority 
of the cases, and others again, in a smaller proportion. In this 
way we learn to connect the constant lesions with the predominant 
symptoms, perhaps to discover that the former were the cause of the 
latter, and, in this way to form a clear and definite idea of the dis- 
ease. If different modes of treatment were employed with different 
portions of the patients, we may be able to estimate the compara- 
tive values of the several methods by counting the proportion of 
deaths in the several groups of cases. 

It has been assumed that the subjects of these 200 cases were 
under precisely the same circumstances of age, social condition, 
&c, that they were perfectly comparable with one another. Now 
it results from observation that many, indeed most affections, are 
considerably modified in their intensity, duration, and gravity, by 
the age, sex, previous health, condition, occupation, residence, &c, 
of the persons attacked by them ; it is also a fact that it is almost 
impossible for one physician to collect a very large number of 
cases so nearly identical in every respect as to be perfectly com- 
parable with one another. Hence the near approach to certainty, 
according to the plan just set forth, is somewhat lessened, first, be- 
cause it is evident that in proportion as the cases in our series dif- 
fer from one another, it will be difficult to deduce from them a 
general law; and, secondly, because the number of similar or 
comparable cases which it is possible to collect being very restricted, 
the conclusions drawn from them will be weaker than if furnished 
by a more extended series of facts. It follows, therefore, that a 
collection of observations made indiscriminately amongst the old 
and young, the rich and poor, males and females, in hospitals and 
in private practice, during ami in the absence of an epidemic, is 

4* 



42 INTRODUCTORY ESSAY. 

not made up of facts susceptible of being compared with one 
another. They must first be separated into as many groups as 
there are distinct and influential modifying causes acting upon the 
patients; each of these groups must be analyzed by itself, and the 
inferences made from it must not be applied to the other groups. 

The following examples illustrate this proposition. Nothing is 
better established than that depletion is useful in pneumonia. Yet 
some years ago there was a prevalent inflammation of the lungs, 
in which, if the patient was freely bled, he died. And why ? be- 
cause the disease was really no longer the same ; it was a pneu- 
monia of a typhoid form, wholly different from the ordinary one, 
and requiring an opposite treatment. The two classes of facts 
were not comparable. Again, suppose that it were desired to 
know the mortality after amputations, and that we had at com- 
mand the reports of two of the largest hospitals in Paris, Hotel 
Dieu and La Charite, into which the same sort of patients, and 
in about equal numbers, are admitted. The average mortality 
derived from the two reports combined, is, say 50 per cent. But. 
upon making a separate average for the two hospitals, we are 
surprised to find that for Hotel Dieu it is 80 per cent., while for 
La Charite it is only 20. We are then informed that the former 
of these hospitals, owing probably to its situation on the river, 
was so notoriously fatal to the wounded, and those who had sub- 
mitted to surgical operations, that the government ordered at least 
one half of it to be torn down. In this instance, also, the two 
classes of facts were not comparable. 

Three precepts may therefore be laid down as fundamental, and 
essential in all researches after medical truth : 1st. That the 
cases must be observed and recorded honestly, minutely, and fully. 
2d. That they must be very numerous, the more so the better. 
3d. That they must be comparable. It is very true that these 
conditions are not easily fulfilled ; the labour, the humiliation of 
intellectual pride, the length of time, the weariness of a pursuit so 
nearly mechanical, are all obstacles in the way, and not easily 
surmounted. But there is no royal road to truth ! 

But it may be objected that this pretended exactness is useless ; 
that it makes no difference whether a disease is said to be mortal 



MKDICAL TJIUTH. 43 

90 times in a hundred, or that it is almost constantly mortal ; 
whether the numerical form of expression, or the adverhial is 
employed, the result is the same, an approximation to the truth 
only is attained ; for the proportion may vary with the next 
series of cases observed, and the numbers used represent no- 
thing absolute or certain. The numerical method, it may be 
replied, is superior to the other, for the same reason that the best 
of everything is better than what is merely good, even when the 
best is imperfect. The method we recommend is acknowledged 
to be imperfect, but it is preferred as being less imperfect than 
others ; its results are, indeed only approximative, but they ap- 
proach nearer to truth than those obtained by any other plan 
whatever ; it is certainly liable to abuse, but much less so than 
any other method, for it is much more probable that a man should 
assert a falsehood than commit a forgery ; that he should say I 
have seen, when he had not, than that he should take the trouble 
of fabricating a series of cases which never existed. The ques- 
tion is not how shall we discover a perfect, absolute, and un- 
erring instrument for revealing to us the laws of disease, and 
certain rules for their cure; that were as impossible as to predict 
the exact shape, dimensions, and duration of the leaf which is 
forming under the warm breath of spring. We may, indeed, 
foretell its general shape and size, the probable period of its 
fall, and its characteristics as the leaf of a particular species or 
variety of tree, but not its individual characteristics. Yet no one 
contests the claim of Botany to be called a science. The same 
thing is true of Medicine. So long as man is human, will our 
science be uncertain, simply because it has to deal with ever 
varying elements; and, therefore, when a plan is proposed for im- 
proving it, it is no sufficient objection that the plan is imperfect. 
If it can be shown to be superior to any other that has yet been 
employed, there is abundant reason for adopting it, even though it 
should condemn much that we have been taught to admire, and 
confute many things we have been accustomed to believe. 

Exact observation and numerical analysis, in the several occa- 
sions for their use, are productive of results by no means uniform 
in valuf. The laws of the physical sciences are certain, just in 



44 INTRODUCTORY ESSAY. 

proportion as the phenomena from which they are derived are 
simple and uniform. On this principle we placed Astronomy at 
the head and Medicine at the foot of the list. There are various 
degrees of certainty in the several departments of Medicine, and, 
for the same reasons, viz. : the more or less complication, and the 
more or less variableness of the phenomena belonging to them. 
The simplest and most positive of all is Pathological Anatomy. It 
may, at first sight, seem strange that this, one of the newest de- 
partments, should yet be the most perfect. But the reason is evi- 
dent. This branch of medical science is concerned exclusively 
with matter, organized indeed, but dead, and susceptible of hardly 
any changes which cannot be readily explained. Form, dimen- 
sion, colour, and consistence, are the few elements to be studied ; 
all of them cognizable by the senses, and capable of being mea- 
sured, that is, estimated by comparison with some fixed standard. 
We have our measures of length and capacity for some of them, 
and familiar hues, and well-known solids or fluids to compare 
with others. It is no wonder that with elements so easily valued, 
and with such cultivation as it has received during the last forty 
years, Pathological Anatomy should be well nigh exhausted, so far 
as the grosser solids of the body are concerned, and that those who 
laboured most to advance it, should now be turning to investigate 
the fluids of the economy; and, armed with the microscope, to 
extend their researches into the minutest recesses of organized 
matter. It is easy to see that the application of number to the 
details of morbid anatomy was natural and inevitable, for the 
measure or weight of anything is more readily expressed in num- 
ber than otherwise, and the constancy with which the same struc- 
tural alterations were observed in the same disease, must have 
suggested the statement of this uniformity or proportion, in nume- 
rical phrase. 

The next most exact application of this method, is to the study 
of symptoms; to the phenomena of living matter, and of the soul. 
As already stated, the admission that there are different diseases, 
is equivalent to that of their symptoms being uniform respectively ; 
of their occurring in one case very much as they do in another of 
the same affection. Some of them are more, and others less con- 



MEDICAL TRUTH. 45 

stant. Some present themselves with unfailing regularity, others 
very rarely, and, as it were, accidentally. From this it is at once 
evident that the relative frequency of a given symptom may be 
expressed in number. But in the large number of symptoms 
which, taken together, serve to characterize a disease, there is 
hardly ever one which is always present, one which is so inva- 
riable as to deserve the name of pathognomonic. The greater 
part only of a given group may be expected to appear, and rarely 
in any two cases, the same part. The recurrence of the same 
symptom, therefore, or of the same group of symptoms, is exceed- 
ingly variable and uncertain, and consequently the numbers ex- 
pressive of their frequency declare no more than an approximate 
truth. If we turn from the frequency to the character of symp- 
toms, we shall find its exact appreciation still more difficult. Take 
two cases of one of the most uniform diseases, small-pox for ex- 
ample, and there will not be found a single symptom in the one 
resembling perfectly the corresponding symptom in the other. 
There will be a difference of duration, of intensity, of extent, of 
sympathy, of effect, &c, and yet these differences are not such as 
to destroy the identity of the symptom, nor to make it unfit for 
comparison with that in the other case, although such compa- 
rison cannot be perfectly exact, nor made entirely by means of 
numbers. We can, indeed, measure the duration of a symptom 
as we can its frequency ; but to what arbitrary standard can be 
referred degrees of pain, the wanderings of the mind, or the per- 
versions of the moral sense? It is only when a very large collec- 
tion of cases has been made, and it is attempted by an analysis of 
them, to arrive at a general idea, definition, or description of the 
disease, that the disparities between individual cases disappear ; that 
number, which was quite inadequate to define the peculiarities of an 
isolated case, is the best possible means of expressing the characters 
of the type, the common features of the whole series of cases taken 
together ; the best, that is, of declaring exactly what symptoms 
ought to be regarded as really characteristic of the disease, be- 
cause ihe only one which can accurately point out the relative 
frequency and importance of the several symptoms. 

The employment of numerical expressions, therefore, may be 



46 INTRODUCTORY ESSAY. 

considered as of the highest consequence in giving precision to 
diagnosis, inasmuch as it is the only mode whereby the symptoms 
of disease, and its anatomical lesions can be accurately described. 
In the course of the preceding remarks, occasion has been taken 
to contrast the results of industry and method, with those attributed 
to genius. Thus far the latter word has been employed in its 
popular sense, and in that attached to it by those who exalt its 
value in medicine; in the sense of an inventive or creative faculty, 
of a natural and inherent power of seizing truth intuitively, without 
the intervention of the mechanical processes which have been de- 
scribed. In that sense we have not hesitated to assert, and have 
endeavoured to show, that so far from conferring dignity on me- 
dical science, or promoting its advancement, this faculty has rather 
contributed to discredit the profession, and to arrest the progress 
of knowledge. Now, we would not be misunderstood, nor be ac- 
cused of teaching that in the investigations of natural science, all 
men's talents are on a level, and that superior industry is alone 
sufficient to establish a claim to superior merit. We do, indeed, 
maintain that without industry and method the highest natural gifts 
are inefficient, and will actually accomplish less than moderate 
abilities sustained by these helps. But we assert that there is a 
genius, not a speculative, not a poetical, not a mere fantastic fa- 
culty, but a practical genius, which is, to say the least, a far more 
rare endowment than that just mentioned ; "a power which is ca- 
pable of penetrating into all things within our reach and knowledge, 
and of distinguishing their essential differences." It creates no- 
thing, it does not even invent anything, it only sees things as they 
are, and discovers truth in what it sees. For the truth, as we are 
told by Rousseau, is in things and not in our minds, and the less of 
ourselves we introduce into our judgments, the nearer we shall ap- 
proach to truth. Such was the genius of Hippocrates, of Sydenham, 
of Morgagni, of Haller, of Laennec, of Abercrombie, of Hunter, of 
Bichat, of Sir Astley Cooper ; such z'sthat of Andral, of Chomel, of 
Louis, of Cruveilhier, of Brodie, of Graves. These men saw re- 
lations amongst the phenomena of disease, which were invisible to 
less gifted men ; and, having seen them by virtue of their genius, 
they did not stop there, and build up a theory upon them, assuming 



MEDICAL TRUTH. 47 

them to be true, but immediately applied themselves to discover 
whether they had seen correctly ; they tested their inspirations by 
observation and experiment, and when they found them unable to 
bear these tests, they rejected them as delusions, as idle dreams, 
not even worth remembering ; but when, on the other hand, they 
found them confirmed, they gave credit, not to the original pene- 
tration which had guessed at the truth, but to the series of facts 
which had established it. Or if these and other great men did 
sometimes form theories, nay, were even famous for their theories, 
what has become of them ? They are regarded as nothing better 
than the vagaries of great minds, defects from which nothing hu- 
man can escape; as spots upon the sun, or clouds upon the sky. 
No one quotes them as authority, no one adopts them as guides, 
no one imitates them as models. Yet the works of these men are 
authoritative, they are followed, they are imitated, but in so far 
as they interpret nature, and no farther. It is hardly worth 
while, then, for the man of genius, like the spider, to spin out ela- 
borate cobwebs to catch the silly flies of to-day, when he may be 
well assured that his work will have perished ere the morrow. He 
may far better, like the Egyptian Kings, spend his life in building 
up a solid pyramid of facts, in which his memory will be em- 
balmed through ages yet to come. 

It is curious to observe what deference, what homage, even, is 
paid to the labours of these " men of no genius," who are unceas- 
ingly employed in hunting for the golden grains of truth amidst the 
sands of error, even by those who are most strenuous for the use 
of reasoning (by which they mean speculation) in medicine, and 
most clamorous against the humiliating processes of the school of 
observation. In the writings of these philosophers par ezcelle?ice y 
whom do you find quoted as the principal authority under the head of 
phthisis? Louis. Whom under that of typhoid fever? Louis. Whom 
under that of emphysema of the lungs? Louis. Whom in the case of 
croup in the adult, of pericarditis, of true gastritis? Louis. Who 
has produced the most perfect treatise extant on pneumonia? The 
only complete history of the diseases of children? The only con- 
sistent account of neuralgia ? The most perfect history of can- 
cerous diseases? The first true statement of the pathology of 



48 INTRODUCTORY ESSAY. 

hydrocephalus; of softening of the brain; of remittent fever; of 
tubercles of the bones; of alterations of the urine; of infantile 
pneumonia? Such men as Grisolle, Rilliet, Barthez, Valleix, 
Walshe, Rufz, Gerhard, Green, Durand-Fardel, Stewardson, Ne- 
laton, Becquerel, and so on. All of these, with a single exception, 
are young men, and yet the authors of works which, by common 
consent, are placed in the foremost rank of the medical authorities 
of the present day. These are the men who have spent their five, 
ten, even fifteen years in the hospitals before entering upon private 
practice ; who have comprehended their profession as a field of toil, 
and not as a garden of amusement; and who, when challenged 
as to their competency, can point their judges to what they have 
achieved, for by their fruits they are known. These are the men 
whose devotion, whose impartiality, whose aversion to hypothetical 
reasoning, whose single-hearted love of truth, whose industry, pa- 
tience, and method, are most earnestly commended to the imita- 
tion and rivalry of American students and physicians, as the only 
qualities which can insure the formation of that national medical 
literature, without which the profession of this country can never 
maintain its rights in the scientific republic of the world. 



ELEMENTS 



GENERAL PATHOLOGY. 



PAKT I. 

ETIOLOGY. 

CHAPTER I. 

PRELIMINARY OBSERVATIONS. 

PATHOLOGY DIVIDED INTO GENERAL AND SPECIAL ; OBJECTS OF 

THE FORMER, AND METHOD OF TREATING IT GENERAL NOTION 

AND DEFINITION OF DISEASE NOMENCLATURE OF DISEASES. 

Pathology is the history of disease. The term is often very 
incorrectly used by medical writers and physicians. By some 
it is employed to express the essential nature of a disease; by 
others, it is used as synonymous with morbid anatomy ; and by 
others, again, is made to include therapeutics. But ignorance 
of the intimate nature of a disease is no more a hindrance to 
its perfect description, than that of the ultimate elements of many 
minerals would be to the study of their physical relations. Mor- 
bid anatomy is a department of pathology, because it describes 
the physical lesions attendant upon disease, which lesions, no 
less than functional symptoms, belong to the phenomena of the 
disease, and although not wholly constituting it, are still to be in- 
cluded in its history. Therapeutics have come to be regarded as a 
division of pathology, because it has been found convenient to treat 



50 PRELIMINARY OBSERVATIONS. 

of the remedies for disease in the same works which describe it ; 
but they have no more necessary connexion with pathology, than 
morality has with crime, or any other remedial agency with the 
mischief it is adapted to cure. 

If pathology is the history of disease, and if each disease is 
marked by certain peculiarities which distinguish it from all others, 
there must be a pathology of each disease, or in other words, a 
special pathology. On the other hand, if many diseases possess 
certain features in common, the description of these features will 
no longer be special, but general pathology. The latter is nothing 
more than a generalization of the facts of the former. 

Special pathology comes first in the order of nature. It is made 
up of individual facts, carefully observed, arranged, and classified 
according to some nosological plan. General pathology collects 
those facts, wherever found, which have a certain similarity, and 
arranges them, according to their natural analogies, so that who- 
ever examines them in this view will have no difficulty in appre- 
ciating them as phenomena of particular diseases. 

Hence it is, that wherever medical education is most complete, 
general pathology is taught as an introduction to special pathology; 
just as in treatises on chemistry, the general laws which have been 
deduced from special experiments and observations are always dis- 
cussed first, so that the learner having obtained correct ideas of 
heat, electricity, affinity, &c, is able to apply them without hesita- 
tion to all the cases in which these agents are concerned. So the 
student of medicine, when he has learned that a certain class of 
causes, symptoms, and lesions, usually coincide, or follow one an- 
other, has manifestly gained knowledge that will be useful to him, 
wherever, or under whatsoever name, that combination of causes, 
symptoms, and lesions may recur. General pathology treats of 
the causes of disease, whether they exist within the individual or 
around him ; of its forms, stages, symptoms, and terminations ; 
describes its ravages in the organs of the human body ; and points 
out the best methods of investigating and interpreting the symp- 
toms furnished by them, in all the morbid conditions under which 
they have been observed. In other words, it includes whatever is 



OBJECTS OF GENERAL PATHOLOGY. 51 

common to diseases in general, and to particular classes of dis- 
eases. 

One object, then, of general pathology, is to place the beginner 
as nearly as possible in the same position as the old and experi- 
enced physician, who, from the summit of the hill which he has 
climbed with toilsome steps, looks back upon the numerous objects 
that have grown familiar during his progress, and embracing them 
all in a single view, perceives their relative bearings and magnitude 
much more distinctly than while he was passing amongst them. 
This knowledge we propose to communicate to the student ; to 
sketch for him the general portraiture of disease ; to familiarize him 
with the language employed to describe it; to mark out for him the 
road he is to travel ; to indicate the objects which chiefly deserve 
his attention, as well as the dangers to which he will be exposed ; 
and the means and instruments he should employ to become ac- 
quainted with the one, and avoid the other. In this work we shall en- 
deavour to lay aside all merely theoretical discussions concerning 
what are generally known as principles of medicine, and which 
are, for the most part, nothing more than hypothetical explanations 
of general facts. To adhere strictly to such a rule is not only dif- 
ficult, but perhaps impossible, for the very language in which an 
event is described frequently involves an hypothesis of its nature, 
and that without any suspicion on the part of the writer that such 
is the case. However difficult, therefore, it may be to avoid spe- 
culation, we shall at least feel bound to attempt it. 

The order in which the several divisions of general pathology 
will be discussed, is based upon the natural succession of events in 
disease. We shall in the beginning endeavour to give a correct 
general idea of disease, and afterwards enumerate its causes, and 
modes of generation. Our attention will next be directed to cer- 
tain general forms or types of disease ; certain varieties of course, 
duration, and termination ; certain differences arising out of the 
seat and extent of diseases ; the various means employed in the 
observation of disease; and general prognosis. From this branch 
of pathology we shall pass to the phenomena presented by the 
several parts and organs of the body in disease, pointing out the 
value of each in positive and differential diagnosis, and as in- 



52 PRELIMINARY OBSERVATIONS. 

dicative of the tendencies of disease. Finally, the subject of 
morbid anatomy will engage our attention, including an account 
of the processes which lead to alterations of structure in the body. 

The word disease is used in two different senses; in a general and 
a specific sense. It may be said of a man that he is diseased with- 
out expressing the manner in which he is affected, just as a flower 
may be said to be coloured without designating its particular hue. 
In both of these cases we receive definite, although negative, ideas; 
in the one that the man is not in health, in the other that the flower 
is not colourless. But the man may have a disease, a pneumonia, 
or peritonitis, as the flower a positive colour. This distinction, so 
plain, and even trivial, to all who are content to receive the evi- 
dence of their senses as superior to the conclusions of sophistry, 
has, nevertheless, been a theme of prolonged and violent discussion 
amongst medical philosophers. There have been men in every age 
who, striving after hidden things, and creating where they could not 
discover, have obscured and complicated a really simple subject 
by their speculations in regard to life, and matter, and the essential 
qualities of that state or thing which we call disease. 

Nor have these barren investigations been conducted by specu- 
lative men alone ; the most sagacious and observant physicians 
have been sometimes tempted to indulge the natural propensity for 
the abstruse and metaphysical, but they have rarely allowed such 
pursuits to wean them entirely from the study of nature, or to 
colour their descriptions of its phenomena. Often indeed they have 
done no more than receive the current philosophy of the day, as 
inherited from former times, or contrived by their non-medical 
contemporaries. Hippocrates taught that there are four humours 
in the body, — blood, phlegm, bile, andatrabile; and that all diseases 
depend upon an excess or deficiency of some one of these. Galen 
inculcated the same idea, admitting, also, a change in the quality 
of the humours. To these notions Paracelsus and the chemical 
school superadded certain reactions amongst the humours. Then 
the mechanical school arose, illustrated by the great names of Bo- 
erhaave and Baglivi, the former of whom proposed a system in 
which the true mechanical properties of the human organism, to- 



GENERAL NOTION OF DISEASE. 53 

gether with a great many hypothetical ones, were assumed to be 
sufficient for demonstrating the intimate nature of disease. Baglivi, 
on the other hand, although fully persuaded of the truth of the 
mechanical hypothesis-, totally disregarded it in practice, and was 
so cogent and eloquent in his praise of observation, and his con- 
demnation of unfounded theory, that his works are even now well 
fitted to excite the admiration of every lover of medical truth. 

Sydenham, the modern Hippocrates, as he has been justly called, 
and whose precepts and example contributed largely to form the 
scientific character of the eminent Italian just mentioned, admitted 
without question the doctrine that disease consists in a struggle be- 
tween the vital and a morbific principle, that by a process ofcoction 
the latter is eliminated, and at the crisis of the disease thrown off. 
But these opinions had little or no influence on the conduct of Sy- 
denham. Cullen,too, the great light of the Scottish school of me- 
dicine, whose descriptions and definitions of disease are unsurpassed 
even by those of Aretseus himself, was the author of the doctrine 
of spasm of the extreme vessels, a purely imaginary state. In our 
own time the teacher, who more than any one else fixed the atten- 
tion of physicians upon the local phenomena of disease, Broussais, 
invented a doctrine in which " irritation" was represented as the 
source of every healthy vital action, and its excess the essence of 
disease, a doctrine world-renowned, and yet obsolete before its au- 
thor's death. 

These instances are cited not at all as a sketch of the history of 
medical theories, but merely to illustrate the assertion that, in every 
age, even those men who have contributed most largely to the na- 
tural history of disease, who have most enlarged and perfected the 
resources of medical art, who have held the soundest doctrines of 
the nature and necessary limits of scientific research : those, in 
fine, to whom medicine is most indebted for its progress, — have 
not been able to divest themselves of a tendency to go beyond the 
evidence of their senses, and to pry into the inscrutable recesses of 
essential causes. 

But what is disease? Does a knowledge of the errors of our 
predecessors enable us to give a better definition than theirs? Va- 
rious attempts have been made to furnish such a definition, but un- 



54 PRELIMINARY OBSERVATIONS. 

successfully. The same principle has guided them all. Since it 
is impossible to know, and therefore to define, the intimate nature 
of disease, it has been usual to frame such definitions of it as will 
include all its sensible phenomena. But hitherto, none has been 
contrived narrow enough for each particular case, and yet capa- 
cious enough to include all. Andral defines disease " to be any 
derangement whatever in the physical or vital laws which govern 
the economy." According to Chomel it is "a notable alteration 
in the position or structure of parts, or in the exercise of one or 
more functions." The authors of a recent work on general patho- 
logy, MM. Hardy and Behier, define it to be " every modification 
of the economy occurring accidentally, and out of the regular 
course of organic action." Dr. Williams paraphrases the defini- 
tion of Chomel, thus : " disease is a changed condition or propor- 
tion of function or structure in one or more parts of the body." 
Finally, according to Dr. Wood, " disease may be defined to be a 
derangement ot the organization, or of one or more of the functions 
of the body." 

Now, in substance, these definitions are identical ; they point to 
the two grand nosological divisions, structural and functional dis- 
eases, instead of confining themselves entirely to some idea com- 
mon to all forms of disease. An attempt is indeed made to express 
this idea by a word of like meaning in each definition. With An- 
dral and Dr. Wood it is derangement; with Chomel, alteration; 
with Hardy and Behier, modification ; and with Williams, change. 
But derangement, alteration, modification, change — of what? 
Evidently of some pre-existent condition ; that is, of health. It is 
clear, therefore, that instead of giving the above ingenious defini- 
tions, it would have been quite as much to the purpose, and far 
more simple, to say with Van Swieten, u disease is a deviation from 
health." This definition, it may be objected is vague, but so is 
disease ; and though wanting in precision it is none the less readily 
apprehended. It is worthy of remark that words which men most 
commonly use without any suspicion of their vagueness are pre- 
cisely those most difficult to be defined. No one has ever given a 
definition of God, of life, of truth, of health, dec, of which men 
believe their ideas so accurate that no good purpose would be an- 



DEFINITION OF DISEASE. 55 

swered by their greater precision. So, in the case of disease, there 
is no more distinct limit between it and health, than there is be- 
tween night and day, at dawn and twilight; and yet light and 
darkness are habitually used to illustrate the most perfect contrasts 
which the mind can conceive. 

Our idea of health is not more positive than our idea of disease. 
It would perhaps be impossible to find an individual without some 
derangement, greater or less, of his functions or organs ; we must 
admit, with Galen, that what is called health is neither absolute 
nor indivisible, but a name applied to such a degree of soundness 
as enables a man, without suffering, to perform the ordinary 
duties of life. Many cases lie in the debatable region between 
health and disease. Such, for example, is a strongly marked 
nervous temperament ; in which the imminence of some definite 
malady is so great, that it is hard to say whether a state of health 
really exists or not. Many malformations are of the same kind, 
as a sixth finger or toe, an elongated prepuce, an imperforate 
hymen ; they are serious annoyances, and may become causes 
and elements of disease, yet they are not diseases. So, too, a 
certain state of a given function may be considered healthful in 
one individual, and morbid in another. A pulse, for example, 
which habitually beats 80 times in a minute, indicates disease 
when it falls to 40 beats in the same period ; but the latter may 
be the natural physiological state of certain pulses, as it is said to 
have been with that of Napoleon. Most persons have but one 
or two stools daily, but not a few enjoy perfect health, although 
they evacuate the bowels but once a week, or fortnight. 

Nature everywhere loves gradation ; abrupt transitions are rare 
in her works. If then we would imitate her, we must frame our 
definitions so as to include not only those instances which partake 
unequivocally of the type to be defined, but those also which by 
almost imperceptible degrees, lose their resemblance to this type 
and acquire that of a distinct or opposite one. If these views are 
correct, it is not possible to define disease more accurately than in 
the terms already enounced — Disease is a deviation, front licaltJi. 

We have next to inquire what is meant by a disease. It is, of 
course, a particular deviation from health, and our notion of it 



56 PRELIMINARY OBSERVATIONS. 

ought therefore to include all the circumstances constituting that 
deviation, whether functional or organic. But as it is quite im- 
possible to retain in the memory all of these circumstances, it 
becomes necessary to select from among them such as are most 
frequently conjoined, and uniformly present ; and that, not only 
to insure our remembrance of them, but also, in order that, by 
giving a name to this group of constant phenomena, we may have 
at command a concise expression by which to designate the 
disease. For this purpose it is evident that not one alone, nor 
even a small number of examples of the disease to be defined, 
will suffice ; the largest number possible of individual cases must 
be collected, arranged, and compared, so as to reveal those phe- 
nomena which are so constant that they may truly be said to 
characterize the malady. It is not enough that these characters 
be taken from amongst the most prominent in the most striking 
cases ; the mildest as well as the severest case must contribute its 
part to this generalization, because it is the business of the physi- 
cian to recognise diseases, even in their least alarming forms. 
The latter are, indeed, those which concern him most, as being 
the most common. 

It has been maintained by some writers, that all diseases have 
their seat in the solids or fluids of the body, or in both, and that 
consequently, the proper definition of a disease must consist 
chiefly in a description of the organic alteration on which it de- 
pends. We are accustomed to look upon all vital acts as func- 
tions of the organs by which they are manifested, and to conclude 
that such acts are impossible without the intervention of the 
organs. From admitting this proposition in regard to the organs 
of organic life, it has at last come to be entertained in regard to 
the brain ; and the soul is alleged by all of such reasoners as aim 
at consistency, to be nothing more than a quality of the cerebral 
substance. 

Aside from the arguments deducible from a necessary belief 
in the separate existence of an intelligent and active spirit, whether 
in the Deity or in the higher orders of created beings, it would not 
be difficult to prove that insanity is a disease, not of the brain, but 
of the immaterial soul, whose instrument it is ; and not much more 



SUPPOSED SEAT OF DISK AS E. 57 

difficult to render it highly probable that very many diseases com- 
mence, not in any tissue, but in the vital principle which informs 
that tissue, and that they may even run their course without 
affecting in any way the arrangement or composition of the par- 
ticles of the body. If this be true, it is unphilosophical to assume 
that a disease consists in a lesion of some particular part, unless 
that lesion can be made evident to the senses. 

No one can deny that the tendency of modern investigations 
has been to prove that a great many affections formerly sup- 
posed to be altogether functional, are accompanied with changes 
of structure ; for pathological anatomy has revealed numerous 
lesions, which, of course, were unknown while dissections 
were neglected, or imperfectly performed ; and the microscope 
many which the scalpel could not unfold, and chemistry many 
which had escaped both of these instruments, besides opening a 
new field of pathological changes in the various fluids of the 
economy. These wonderful results have disposed not a few 
ardent and impatient minds to anticipate the reduction of all pos- 
sible maladies to the same class with those having a decided 
physical lesion, and to argue that, if in certain maladies we cannot 
now detect any alteration either of the solids or fluids, it is 
owing entirely to the imperfection of our means of observation. 
But however probable the existence of structural lesions in all 
diseases may be, upon the ground of the analogy just mentioned, 
their non-existence in some cases is equally probable, according to 
the argument adduced a moment before. To admit or reject them 
wholly in the present state of our knowledge, would be to travel 
beyond the record, and forsake facts for hypotheses. 

It would seem to follow from the preceding remarks, that the de- 
finition or name of a disease, should not be drawn entirely from 
its real or supposed anatomical character. This latter should 
enter into the short description used to define the disease, but the 
name ought rather to be derived from some constant and striking 
feature of the affection, either structural or functional. When no 
change of structure can be detected by any of the means at our 
disposal, the definition should include the most prominent symptoms 
only, as in the case of nearly all diseases of the nervous system. 



58 P R E L I 31 1 If A R Y. O P> S E it V A T I © N S. 

Yet the nomenclature even of these has been, from time to time, 
improved by the discovery of new lesions of the nervous centres, 
and a condition formerly regarded as essentially the same in all 
cases, been found to depend upon different organic states. An apt 
illustration of this fact is presented by paralysis, which is no 
longer described by good pathologists as an independent disease, 
but as a symptom of several structural alterations of the brain and 
spinal marrow, or of pressure upon a nervous trunk. So, too, 
tetanus must be considered as sometimes constituting a separate 
morbid state, supposed now to be functional, and sometimes as 
symptomatic of spinal meningitis. 

But the error which has been pointed out as so prevalent in re- 
cent times, of naming a disease from its ordinary anatomical cha- 
racter, is perhaps quite as chargeable against the ancients. This 
is emphatically true in regard to external diseases, or those general 
disorders attended with cutaneous eruptions. Thus we have va- 
riola, from vari, pimples ; urticaria, from urtica, a nettle, because 
the eruption resembles that produced by the stings of the nettle ; 
and so on, through all the exanthemata. The modern anatomical 
school of pathologists has done no more than extend the principle 
of the ancients in naming diseases, by giving them titles derived 
from internal structural lesions, of which the ancients were igno- 
rant. 

The name of a disease, then, should be conferred in accordance 
with the following considerations. The first alteration of the eco- 
nomy upon which all the subsequent ones depend, is evidently the 
essential element of the disease. But as this is not often discover- 
able, the first tangible link in this chain of causation must be used 
instead. This will generally be found to be an organic lesion, i. e. 
a notable change in the solids or fluids. If such change cannot be 
detected, the most characteristic symptoms should furnish the title ; 
and, finally, if death immediately follows the application of the 
morbid cause, the name of the disease will be that of the cause cf 
death. As examples of the first class may be mentioned pneu- 
monia, pseudo-membranous laryngitis, tubercular consumption, 
cancer of the stomach, &c. ; of the second, epilepsy, typhus fever, 
diarrhoea, &c. ; and of the third class, death from lightning, from 



NOMENCLATURE OF DISEASES. 59 

drinking cold water, from a blow upon the stomach, from terror, 
from prussic acid, &c. It follows, from these principles, that the 
names of diseases should not be considered unalterable. They 
must change as our knowledge increases. Many which were once 
named after their symptoms, are now called according to the lesion 
from which most of those symptoms proceed. In our nomencla- 
ture and definitions we should not be constrained by the rules of 
any exclusive theory ; neither resolving with some to see nothing 
in diseases beyond a group of altered functions ; nor, with others, 
imagining that we have detected the secret and intimate essence of 
morbid states; nor, yet, with others, exceeding the warrant of our 
present imperfect knowledge, and assigning to each malady its 
distinct physical lesion. It were far better to rest satisfied with the 
simple truth, and suffer the imputation of advocating a defective 
system, rather than expose ourselves to the charge of engrafting 
on the tree of knowledge, the barren branches of our own conceits. 
By degrees, if this rule is adhered to strictly, the titles given to 
diseases will answer their purpose more completely, and become 
more and more expressive. But this improvement, to be useful 
and enduring, must wait upon the tardy growth of science, and 
not be undertaken in a ruthless spirit of innovation. 



CHAPTER II. 



.ETIOLOGY PROPER. 



SECTION I. 

CAUSE DEFINED CLASSIFICATION AND DESCRIPTION OF CAUSES. 

The word cause is used in two senses. In the one, it signifies 
that invisible power and mysterious bond which connects two suc- 
cessive events ; not the antecedent, merely, of an event, but its 
efficient antecedent, or that without which it could not have taken 
place. For example, when undigested food excites convulsions, or 
a splinter in the flesh inflammation, it is evident that there is some 
power intermediate to the irritant and its effects in both instances, 
because undigested food does not always induce convulsions, nor 
splinters in the flesh inflammation. This power, if it were known, 
or could be known, would be a true cause, or as it is usually called, 
a proximate or efficient cause ; but it may be conjectured to be a 
purely vital action, and therefore wholly beyond our comprehen- 
sion. The investigation of proximate causes is very interesting, 
and besides having a tendency to give logical acuteness to specu- 
lative minds, contributes directly to the discovery of many links 
in the chain between events which appear to depend immediately 
upon one another. Thus, in the instance just cited, of inflamma- 
tion, it has led to a knowledge of numerous phenomena which fol- 
low the application of the cause, and precede the appearance of the 
symptoms proper to this state. 

The other sense of the word cause is the only one which here 
concerns us. It has been well defined " as the antecedent or con- 
currence of antecedents, upon which a phenomenon is uncondition- 
ally and invariably. present." 



THE CAUSES OF DISEASE OBSCURE. 61 

Unfortunately, there are, perhaps, no causes of disease which 
strictly fall within this definition, for there are none, except in 
two or three specific maladies, which are invariably and uncon- 
ditionally present. Hence, it becomes necessary to regard as 
causes, those which are present in the large majority of instances. 
Diseases arise under circumstances so wholly dissimilar, that dif- 
ferent, and even opposite causes must be assigned to the same 
affection. That is to say, different causes appear to produce 
identical results, but only appear to do so. Thus, diarrhoea may 
follow the application of cold to the surface of the body, or the 
presence of some irritating substance in the bowels, or an impres- 
sion upon the mind. In each case, the apparent cause of the dis- 
ease is different, but beyond doubt, in each, also, the diarrhoea may 
have had some common antecedent ; as, for example, the sudden 
plenitude of the blood-vessels of the alimentary canal. But so long 
as this common element remains undemonstrated, it is necessary 
that the nearest tangible antecedent of the disease should be viewed 
as its cause. 

The intensity of morbid causes, the circumstances under which 
they act, and the conditions of the individuals subjected to 
them, are so infinitely various, as to render it quite impossible 
that any great uniformity should be found in their effects. The 
individual who, to-day, is proof against the infection of an epide- 
mic malady, may, by the loss of a single night's rest, become its 
easy victim on the morrow. Of a large number of persons ex- 
posed to the same morbid influence, no two may be affected in pre- 
cisely the same way. A certain degree of heat or cold, or stimu- 
lation of any kind, may not only be well supported, but enjoyed, 
and yet a very slight augmentation of the same action may give 
rise to violent or destructive disease. Examples of a like descrip- 
tion might be multiplied, but these suffice to show, that in setiology, 
as in other departments of medicine, there can be nothing more than 
an approximation to truth. It is impossible to predict with certainty, 
that a particular effect will result from the application of a given 
cause, and equally so, to assert which one, out of all possible in- 
fluences, may have given rise to a particular case of disease, unless 
those immediately antecedent to the attack be minutely detailed. 





62 ETIOLOGY. 

If, then, some portions of the ensuing remarks should appear to 
be#ague, and less precise than the practitioner desires, let it not 
be forgotten, that the subject is one whose propositions admit only 
a low degree of probability, and that this amount of proof has 
been still further lessened by the very negligent and superficial 
manner in which medical observers have generally been con- 
tent to inquire into the causes of the affections submitted to their 
treatment. Daily observation proves that no error is more com- 
mon amongst the vulgar, than the attribution of effects to wrong 
causes, and that, in fact, one half of the grossest of popular super- 
stitions spring from this source. It is no more than was to be 
looked for, that physicians who relied upon the testimony of their 
patients for ascertaining the causes of disease, should adopt, and 
by their writings perpetuate, the mistakes of the ignorant. The 
human mind instinctively demands a cause for every event, and in 
its eagerness to be satisfied, as readily adopts the apparent as the 
real explanation. 

CLASSIFICATION OF CAUSES. 

The causes of disease which have been admitted as legitimate 
subjects of investigation, may be arranged in two principal classes, 
the predisposing and the exciting. By predisposing causes, are 
meant, those which produce in the economy, certain changes which 
prepare it for the development of disease. They are usually slow 
and gradual in their operation, and not always cognizable, except 
by their effects. Such are the influence of climate, of sex, tempe- 
rament, habits of life, &c. They may be either general or special ; 
acting upon many at the same time, or upon a single individual. 
Exciting causes are those from which disease more directly 
springs. In this class may be included general exciting causes, 
or those which give rise to disease without determining either its 
nature or its seat : special exciting causes, which, while they oc- 
casion, for the most part, definite morbid states, are not the only 
ones from which those states may arise ; such are nearly all those 
causes of disease, which act according to physical or chemical 
laws, and whose action can. therefore, be explained by those laws ; 



CLASSIFICATION OF MORBID CAUSES. 63 

and, finally, specific causes, which not only engender distinct dis- 
eases, but are alone capable of exciting the diseases which follow 
their application ; such are miasmata, and the several sorts of 
virus. Of these last it is further to be observed, that their mode of 
action is inexplicable by any known laws, and that their substan- 
tial existence is rather to be inferred from the uniformity of their 
effects, than from physical demonstration. 

This classification of causes is not to be received as absolute, but 
merely as a more convenient arrangement than any other, under 
which to study the multifarious conditions which remotely or im- 
mediately occasion disease. The same agency may at one time 
act by creating a predisposition, and at another, by directly exciting 
disease. Thus, unwholesome food may give rise to a chronic con- 
stitutional affection, or to an acute inflammation, according as it 
is habitually or occasionally used. What is generally regarded as 
a mere predisposition, may by its prolonged duration directly de- 
velope disease without the evident intervention of any proper ex- 
citing cause, as where scrofula supervenes upon that state of the 
system which is termed the strumous constitution, or diathesis. 
But it is to be remarked in reference to this and similar illustra- 
tions, that the separation between the diathesis and the disease, is 
more artificial than real, the former being, in most cases, nothing 
more than the first or incubative stage of the latter. Even speci- 
fic causes, whose operation is, of all others, the most independent, 
cannot be said in every case to produce their peculiar effects, with- 
out a predisposition on the part of the individuals attacked. Thus, 
the virus of small-pox would at first sight appear capable of gene- 
rating the disease in all persons to whom it is applied ; the suscep- 
tibility to it would seem to be universal. Yet it is notorious, that 
some escape the malady though frequently exposed to it, and even 
cannot be made to receive it by inoculation. It is still more a 
matter of common observation, that some children may be vacci- 
nated repeatedly, before the operation proves successful. Hence, 
a cause of one sort may, by a peculiarity in its action, come to be- 
long to another class of causes, or fail to display its appropriate 
power, unless conjoined with one of another class. 



64 ETIOLOGY. 

SECTION II. 

GENERAL PREDISPOSING CAUSES. 

The greater number of the causes to be now considered consist 
in certain prevalent constitutions of the atmosphere, or in certain 
local influences, either natural or accidental. The alterations of 
the atmosphere which generate disease, do not, so far as can now 
be known, affect its gaseous components, but belong to its tempera- 
ture, degree of moisture, and dryness, and to the effluvia which it 
holds in suspension. To these may be added its electrical state, 
which, however, depends so immediately upon the hygrometric 
condition of the air, that but little advantage can arise from con- 
sidering it separately. 

Temperature, fyc, of the Air. — A high temperature appears to 
favour activity in all the peripheral portions of the circulation, and 
when long continued, to give rise to inflammations of the brain, 
the skin, and the digestive organs. It is supposed, also, by dimi- 
nishing the activity of the respiratory function, to augment that of 
the liver, which, like the lungs, gives exit to a large portion of the 
carbonaceous matter in the system. On this account, it is thought, 
hepatic diseases are so much more prevalent in tropical than in 
temperate regions. 

But great heat, if the air- remain dry, is usually much less pro- 
lific of disease than when accompanied with humidity. In the lat- 
ter case, the disposition to inaction which heat alone creates, is 
sensibly augmented ; the skin, no longer able to part with the 
moisture of the body, and by its evaporation, to maintain a tolera- 
ble temperature, is continually bathed in perspiration; the fluid 
which would otherwise have escaped from this emunctory, is 
poured forth by the mucous membrane of the bowels, and the va- 
rious forms of intestinal flux, diarrhoea and dysentery, prevail. 
It is this association of atmospheric influences to which must be 
chiefly attributed that most fatal scourge of infancy in this coun- 
try, the summer complaint, or clwlera infantum. It is the same, 
also, which appears to be a principal element in the generation of 



TEMPERATURE SEASONS. 65 

those pestilential maladies which devastate the neighbourhood of 
marshes, and certain other moist localities, although, as will be 
more fully shown hereafter, other agencies contribute to, and in- 
deed determine this result. It is remarkable, that although hot, 
dry air predisposes to cerebral, cutaneous, and intestinal inflamma- 
tions, the lungs should be nearly always exempt from disease in such 
an atmosphere, and scarcely less so in warm, and moist weather. 

Cold, on the other hand, while it spares none of the organs, 
hardly, which are deranged by heat, acts with peculiar violence 
upon those of respiration, possibly because their functions are no- 
tably augmented by a low temperature. Hemorrhages and in- 
flammations of the lungs are the frequent results of this cause, as 
are, indeed, these morbid states in other parts of the body. In 
general, dry, cold air imparts to diseases an acute inflammatory 
type, while, on the other hand, a cold, moist atmosphere predis- 
poses to chronic affections, or to those acute disorders which are 
peculiarly liable to become chronic, such as rheumatism and bron- 
chitis ; dropsies, with all their various organic causes, and all the 
forms of tubercular disease, are ordinary effects of this cause. 
In a word, the combination of cold with moisture is more prolific 
of disease than any other cause, or union of causes whatever. 

Seasons. — Heat and cold, dryness and moisture, already noticed 
in a general way, deserve attention also in their natural and ordi- 
nary combinations. One of the most interesting of these is the 
seasons. The influence of winter and summer may be inferred 
from the remarks which have been made respecting extremes of 
temperature. It results from the statistical accounts of the mor- 
tality in Great Britain, that the greatest number of deaths takes 
place in winter ; spring follows next on the list, then autumn, and 
last of all summer. This succession appears also to hold in the 
northern parts of this country ; but the neglect of the subject of 
registration of deaths elsewhere, renders it impossible to surmise 
whether the same proposition is true of those places which are 
visited by epidemic maladies in the summer and autumn. 

The diseases of spring and autumn present a remarkable con- 
trast. Those of the former are generally more acute, their symp- 
toms more distinct, their duration shorter ; they arc more amenable 

6* 



66 -ETIOLOGY. 

to treatment, and less subject to relapses. Haemorrhages, in- 
flammations of the throat and chest, and in our climate, quotidian 
and tertian intermittents of a mild type, are peculiarly frequent at 
this season. Autumnal disorders, on the other hand, are more 
slowly developed, their characters more uncertain, their form is 
more insidious ; they are more protracted, much more difficult to 
cure, and more subject to relapse, as well as to leave behind them 
organic alterations. Thus the liver and the spleen very commonly 
remain affected after the remittent and intermittent fevers of the 
Middle and Southern States. At this season, all diseases of mala- 
rious origin prevail in warm climates ; and in more temperate re- 
gions, affections of the digestive tube abound, being directly excited 
by the sudden alternations of temperature between night and day, 
and by the imprudent use of fruits. 

Climates. — These form a most interesting subject of study in 
their relations to the physiology of the human race, their connexion 
with the customs and physical peculiarities of different nations, and 
with the progress of civilization; but the present view of them must 
be limited to their influence in the production of disease. Climates 
are usually divided into cold, temperate, and hot, corresponding 
to the three great zones of each hemisphere. This division, though 
sufficiently correct in regard to the great spaces embraced in it, is 
not so in the case of particular localities. The latitude of a place 
is not a true index of its average temperature. The climate of 
Lisbon, for instance, is very different from that of Philadelphia, 
which lies under the same parallel, and the character of neither 
climate can be very accurately inferred from its geographical posi- 
tion. Such contrasts are, however, most striking between places 
on the eastern coast of America, and the western coast of Europe ; 
but if the former is compared with the corresponding portion of the 
Asiatic continent, the same climate will be found in both near the 
same degree of latitude. Thus, while Philadelphia is so much cooler 
than Lisbon, its mean annual temperature is nearly the same as 
that of Pekin, which is in the same latitude as the other two cities. 
In polar and intertropical regions, where the temperature is ex- 
treme, we must chiefly look to find proof of the indirect or predis- 
posing influence of climate in producing disease; the moderate 



CLIMATES. 67 

average temperature enjoyed in other regions of the earth's surface 
tends rather to the preservation of physical soundness in the hu- 
man race; and, indeed, it is within the temperate zones that the 
most surprising instances of active power and of endurance have 
been exhibited; their climate lacks the steadiness required in a pre- 
disposing cause, it rather operates by its vicissitudes directly to ex- 
cite disease. 

Cold Climates, — The inhabitants of polar countries, are subject 
to the immediately mischievous effects of intense cold, such as 
freezing of the extremities, of the nose and ears, and inflamma- 
tions of the eyes, either from the action of piercing winds, or 
from the glare of sunlight reflected from the snow, and their dis- 
eases arising from accidental causes are apt to assume a low 
type. The barrenness of the soil, and the short period during 
which it can be cultivated, affords them a meagre supply of 
grain, and almost entirely deprives them of the ordinary products 
of the kitchen-garden. Hence scurvy is a frequent and fatal ma- 
lady in cold climates ; indeed, it was quite unknown in medical 
history, until regular intercourse became established between the 
north and south of Europe. 

The depressing influence of cold, with the filthy habits, and the 
close unventilated dwellings of the people of arctic regions, is 
doubtless a principal reason of the singular violence of contagious 
diseases, when once introduced amongst them ; small-pox and 
typhus fever are, under these circumstances, unusually fatal. Tu- 
bercular consumption is said to be unknown in northern climes; 
but those who go thither affected with the disease, are pretty sure 
to find its progress accelerated. The native of the extreme north 
cannot remove to temperate regions without experiencing all the 
mischiefs which result from the abstraction of his habitual sti- 
mulus, cold ; and if, as an antidote to relaxation and debility, he 
makes as free use of alcoholic liquors and concentrated food as 
when at home, he is very apt to be attacked with diseases of a 
seemingly inflammatory type, but for which he is as little able to 
endure depletion, as the drunkard for delirium tremens. In like 
manner, the native of temperate regions, on migrating to tropical 
climates, is subjected to powerfully debilitating influences ; he is 



68 .ETIOLOGY. 

very apt to fall a victim to some endemic malady ; and the more 
so, if he attempts to carry with him his former habits of life. 

Te?nperate Climates. — The countries of Europe which are gene- 
rally said to enjoy a temperate climate, are situated between 45° 
and 63° of northern latitude. Within these limits, as has been 
stated, the human race acquires its most perfect physical develop- 
ment, and all that it does is marked by energy. And so of its 
diseases. They are, for the most part, sthenic ; characterized by 
powerful reaction, and the inflammatory type, they tolerate de- 
cidedly antiphlogistic treatment, and that not unfrequently even 
when they prevail epidemically. Affections of the lungs and heart, 
with rheumatism, are more prevalent in these than in other coun- 
tries. In America, the limits of the temperate region must be in- 
cluded between other degrees of latitude. Jts southern boundary 
should perhaps be placed about the latitude 39°, on the eastern side 
of the Alleghanies, and, west of these mountains, on the lower 
boundary of Tennessee, in latitude 35°. In all of this extent, in- 
flammatory affections prevail ; nor can it be otherwise, since the vi- 
cissitudes of temperature are greater there than in any other part of 
Christendom. The difference between the mean temperature of the 
hottest and the coldest month in the year, is 45° Fahr. at Phila- 
delphia, while it is but 31° Fahr. at Paris. 

The extreme heat and cold of the climate of so large a portion 
of the United States, has probably some tendency to enervate the 
inhabitants, by exhausting their strength during the summer 
months, and habituating them to the close air of overheated rooms 
during the winter. The prevalent custom, in our large cities, of 
warming houses with hot air, may, like putting plants in a conser- 
vatory, prolong the lives and increase the comforts of the delicate 
and sickly, but it can have no other influence on those of good 
constitution than to render them effeminate, and subject to all the 
maladies incident to a climate not only capricious, but violent in its 
caprices. 

Warm Climates. — The influence of warm climates is much 
like that already attributed to excessive heat. In the torrid zone, 
the mean annual temperature is between 70° and 80° Fahr., and 
upon the islands within the tropics, the range of the thermometer 



WARM CLIMATES. 69 

is very slight indeed. Thus, in the West Indies, it is stated by 
Sir James Clark not to exceed six degrees. Upon the continent, 
however, the diurnal change of temperature is sometimes extreme. 
Dr. Forry tells us that in East Florida, during the month of Jan- 
uary, the thermometer, at mid-day, in the shade, stood at 84° 
Fahr,, but often, just before daylight, sank to 45°. Nocturnal 
variations of temperature are amongst the most powerful exciting 
causes of disease in hot climates. 

In these regions, the inhabitants present the traces of indolent 
and luxurious habits ; they are altogether unfit for prolonged ex- 
ertion, or for endurance of any sort, while they are easily impelled 
to sudden and brief action ; their passions are strong, but, like the 
gusts which devastate their fields, end quickly in a violent explosion. 
The ordinary food of the natives of tropical countries is composed 
chiefly of vegetables ; but, for the proper digestion even of this, 
some artificial stimulus appears to be required, and it has been 
bountifully provided in the shape of spices and various condiments 
which are produced only under the burning sky of the south. 

The diseases which prevail in these climates, are chiefly known 
as they have been observed amongst European colonists, their de- 
scendants, and the aborigines in immediate contact with the settlers. 
Hence, it is not strictly correct to attribute to the peculiarities of 
the climate, many disorders which might more properly be traced 
to constitutions and habits brought from a distance, to be per- 
petuated under a foreign sky, and engrafted upon a stock with 
which they have no natural harmony. Many of the diseases of 
the natives, where colonies have been planted, are due to the vices 
of the emigrants, and to the passion of uncultured people for imi- 
tating those whom they regard as superiors. When, therefore, 
we speak of bilious derangements, and intestinal disorders as pre- 
valent in hot climates, the remark is rather to be understood as 
applying to persons whose constitutions or habits of life are such 
as belong to inhabitants of temperate regions. 

It is well known that strangers not unfrequcntly escape attacks 
of malarious disease, where such affections are endemic, by con- 
forming themselves strictly to the mode of living adopted by the 
natives. A striking example of this sort is related by Dr. Copland. 



70 .ETIOLOGY. 

When travelling in the most unhealthy parts of intertropical Africa, 
he met with an Englishman who had lived there between thirty 
and forty years, and was then in the enjoyment of health. This 
person ascribed his exemption from disease entirely to pursuing, as 
closely as possible, the modes of life of the natives, and adopting 
both their diet and beverage. Until he did this, he had continued to 
suffer from the effects of the pestilential climate. This leads to an- 
other view of the influence exerted by climate in the production of 
disease, and of that process which all new comers into a country 
different from their own, in soil, air, temperature, &c, must un- 
dergo, and which is called, — 

Acclimation. — Emigrants from a cold or temperate to a warm 
climate are apt, soon after reaching their destination, to suffer from 
symptoms of plethora, which often terminate in the discharge of 
blood from some one of the mucous membranes, that of the nose, 
the bowels, and less frequently the lungs. They are also very 
liable to be attacked by inflammation of the brain, or liver, by 
dysentery, or by the remittent, or yellow fever peculiar to the 
locality. The nervous and vascular systems are excited by the 
augmented temperature; the lungs evince less activity, and the 
urinary and intestinal excretions decrease, while those of the liver 
and skin are considerably augmented. So complete a revolution 
in the functions of the economy must of course increase the liabi- 
lity to disease; but why it should give rise to the particular 
diseases which attack the unacclimated, is by no means clear. 
Yet many writers upon this subject have no difficulty in finding 
in it a sufficient explanation of the " febrile attacks," of the inordi- 
nate secretion " of acrid bile," &c, which occur under these cir- 
cumstances ; and some have even asserted, in the same spirit, that 
the influence of a vertical sun upon the head " is productive of 
diseases both of it and of the liver" The same diseases do not 
affect natives and acclimated persons alike, nor at the same season 
of the year ; so that, when the one class is sickest, the other en- 
joys the best health. During winter the natives sufler most ; the 
degree of cold is sufficient to produce amongst them, to some ex- 
tent, the inflammatory affections familiar to more northern coun- 
tries, while foreigners, from those countries, find the temperature 



ACCLIMATION. 71 

much milder than they had been accustomed to, and are seldom 
ill during its continuance. At Rome, in the month of April, when 
the fields are already blooming, and the strangers in the city are 
sallying out in their summer garments, the Romans may be seen 
closely wrapped in their ample cloaks, and even then shuddering 
if they walk in the shade. 

When the parching heat of a tropical summer succeeds to the 
mildness of the winter, the unacclimated suffer, in their turn, with 
inflammations of the brain, liver, and bowels, while the natives 
enjoy a more complete exemption from disease than at any other 
period. Still later, from July to October, when the air becomes 
loaded with humidity, the endemic maladies of the tropics prevail, 
and decimate the foreign population ; remittent, intermittent, and 
yellow fevers, dysentery, the plague, and cholera, cut off multi- 
tudes of the unacclimated, many residents of European descent, 
and many natives who have adopted the habits of foreigners, and 
at the same time their susceptibility to disease. 

The dangers of a hot climate to those accustomed to a lower 
temperature, are greatly aggravated by ignorance, and by impru- 
dent habits of life. A resort to stimulating food and drinks with 
a view of counteracting the enervating effects of the heat, can 
hardly fail to bring on the very maladies they are intended to pre- 
vent, by destroying the tone of the stomach, augmenting the ner- 
vous susceptibility, and increasing the biliary secretion much be- 
yond the wants of the system. These appear to be the sources of 
that remarkable proneness to ill-health which exists among the 
English residents in India. The natives of Great Britain, more 
than any other people, carry with them into foreign countries the 
modes of living which nothing but an inclement sky could render 
excusable in any place. Their fondness for animal food, and for 
malt and spirituous liquors, and strong wines, is scarcely less ex- 
treme when they live under a tropical sun, than amidst the fogs 
and showers of their native land ; and to these causes their own 
medical writers attribute the high rate of mortality in the southern 
colonies of Great Britain. 

Along with such errors of diet, or apart from them, as a cause 
of disease amongst the unacclimated in hot climates, must bo men- 



72 ^ETIOLOGY. 

tioned the excessive use of sub-acid fruits, and other vegetable 
productions, which there abound ; they are especially apt to be 
prejudicial to newly arrived emigrants, who have perhaps been 
almost entirely restricted to the use of animal food during a long 
voyage, and are therefore more prone to indulge their appetites in 
a novel and agreeable diet. 

Foreigners, however, are not the only persons liable to diseases 
of acclimation in tropical countries. Natives who have been 
absent for several years, are, on their return, scarcely less apt 
than strangers to contract the endemic diseases. A case is men- 
tioned by MM. Hardy and Behier, in which a native of Cuba 
suffered three several attacks of yellow fever, at intervals of as 
many years, he having, during those intervals, resided in Europe. 

It is by comparing the diseases of countries most dissimilar in 
their temperature, that the most striking illustrations of the morbid 
influences of climate are to be obtained ; but others not less de- 
monstrative of the reality of such influences are constantly met 
with on observing the effects of comparatively insignificant changes 
of residence, as from the mountains to the plains, from the interior 
of a country to the sea-side, from the city to the country, from a 
northern to a southern exposure, and in each case, conversely. 
Here we find exemplified on a small scale, the effects which have 
been ascribed to the several sorts of climate ; forms of disease 
varying with temperature, dryness or moisture, the prevalent 
winds, the vicinity of narshes, &c, and which are much more 
apt to attack strangers than residents in the several localities. 
Some of these influences will call for notice amongst the exciting 
causes of disease. 

There are several other conditions which admit of being ranked 
amongst general predisposing causes, since they may operate as 
well on masses as upon individuals. Such are wet clothing, which 
may give rise to various forms of ill-health in a large part of an 
army, or of a ship's crew, at the same time ; putrid food, foul 
water, the want of bread or fresh vegetables, the emotion of fear 
or anxiety, causes which operate fearfully in camps, and ships, and 
in beleaguered towns, in time of war. Other emotions of the 
mind are also productive of disease. Chomel stales that the in- 



HEREDITARY PREDISPOSITION. 73 

fluence of chagrin and disappointment upon the French soldiery 
was very apparent, after the disastrous campaigns of 1813 and 
1814. The cases of sickness multiplied with frightful rapidity, 
when fortune ceased to favour the imperial standard. The social 
condition of a people has a distinct influence on their diseases ; 
this is nowhere so plainly seen as in the prevalence of insanity 
amongst civilized nations, its rare occurrence amongst barbarians, 
and, in the former, its exact proportion to the degree of political 
liberty possessed by them. The people of the United States are, 
politically, the freest in the world, and they also occupy a sorrowful 
eminence as furnishing, in proportion to their number, more cases 
of insanity than any other people. 



SECTION III. 

SPECIAL PREDISPOSING CAUSES. 

These are for the most part, peculiar to the individual. They 
include all that he is by virtue of his birth, age, sex, temperament 
and constitution, and all that he has been made by his trade, pro- 
fession, condition of life, his previous diseases, his residence, 
clothing, food, and other circumstances, called hygienic ; in other 
words, this class comprises all natural and acquired tendencies to 
disease. 

Hereditary Predisposition. — Baillou has remarked that "pa- 
rents transmit to their children disease as well as wealth, but the 
former much more certainly than the latter." It is indeed too 
often the case that a parent's early prodigality and debauchery 
permit him to bequeath no legacy to his children but his infirmities ; 
a sad entail, which no human laws can break. There are family 
diseases, just as there are family features, and peculiarities of gait, 
gesture, or character. It would therefore, even apart from actual 
observation, seem probable, that whatever maladies depend upon 
peculiar organization would be hereditary ; but observation fur- 
nishes abundant facts to illustrate this subject, proving conclusively 
the existence of morbid tendencies transmitted from generation to 

7 



74 ^etiology. 

generation, although it gives no certain clue to the laws which 
regulate the transmission. 

Of the affections generally admitted to be propagated in this 
manner, the most prominent are tubercle, cancer, organic diseases 
of the heart, emphysema of the lungs, insanity, epilepsy, gout, 
gravel, and apoplexy. It is not to be understood that either parent 
need be suffering from a transmissible disease at the period of the 
child's conception or birth, in order to its subsequent develop- 
ment, although the probability of this result is increased by the 
parent's being then affected with such a disease. In general, the 
predisposition only, and not the disease itself, is transmitted ; for 
this latter does not usually make its appearance until adult life, or 
until after the age of puberty, and even then it often appears to be 
the result of habits of living, or other causes, competent of them- 
selves to produce it, without any taint of the ancestral blood. But 
these very habits 3 &c, are commonly an evidence of the influence 
of the parents' constitution ; for tastes, talents, and propensities, 
are inherited just as certainly as form and feature. It occasionally 
happens that an hereditary disease, in the sense just explained, be- 
comes so in the vulgar sense, that is to say, is communicated to 
the child in the womb, and affects it at birth. This may be the 
case with tubercles and other forms of scrofula. But with these 
exceptions, all diseases of the foetus are original, and independent 
of either parent. Syphilis and small-pox may be directly trans- 
mitted from the parent to the child. 

The diseases of the mother are said to be more certainly trans- 
missible than those of the father; and this opinion, founded on ex- 
perience, is confirmed by the prevalent belief of breeders of cattle, 
that the peculiarities of the dam are much more likely than those 
of the sire to be reproduced in the offspring, and, also, by the nu- 
merous instances in which distinguished persons have been born 
of mothers remarkable for energy of character, and the rare ex- 
amples of greatness among the sons of eminent men. In some 
instances several members of one generation in a family are affected 
with the same disease, although neither of the parents may ever 
have suffered from it. Dr. Holland mentions two families in which 
three brothers severally underwent attacks of hemiplegia ; one also 



HEREDITARY PREDISPOSITION. AGE. 75 

in which three sisters had epileptic fits; and another where four 
children died during infancy from affections of the brain ; yet in 
none of these examples had either father or mother been affected 
with diseases like those which attacked their children. Here a 
strongly marked predisposition must be admitted, and although the 
hypothesis of its hereditary character may allow of some dispute, 
it seems more probable than any other. 

Another variety in the hereditary transmission of disease is its 
being confined more or less completely to the males or females of 
the family affected ; or it may happen that the males may be sub- 
ject to one malady and the females to a very different one. Now 
the mother conveys disease to her daughters, and now the 
father to his sons, and in other instances, again, the morbid influ- 
ence appears to pass from one sex in the parent to the opposite 
sex in the child. In certain cases, as of secondary syphilis, every 
other child has presented signs of infection. In others, again, 
whole generations profit by this sort of intermission ; the grand- 
father and the grandson, the father and the great-grandson being 
similarly subject to, or exempt from the hereditary affection, as in 
the case of gout and insanity. It is another fact in the history of 
hereditary diseases that many have a tendency to evolve them- 
selves at a period of the child's life, which is most likely to be 
that at which the parent was first attacked. The melancholy 
spectacle is not unfrequently presented of all the members of a 
large family cut off by the same disease on arriving at a certain 
age. 

The age at which the hereditary tendency displays itself in the 
development of a particular disease depends upon the nature of that 
disease. None that is clearly hereditary, except the glandular 
form of scrofula, becomes manifest anterior to the age of puberty. 
Subsequent to this epoch we meet with, first, tubercular consump- 
tion, epilepsy, and insanity ; in the early part of adult life emphy- 
sema of the lungs and hypertrophy of the heart, and somewhat 
later, gout, gravel and apoplexy. 

Age. — Age is not, strictly speaking, a cause of disease; but 
each of the different epochs of existence is more liable to some dis- 
eases than others, and may therefore be regarded as predisposing 



76 ETIOLOGY. 

to them. Some diseases never appear before a certain epoch, 
and some are almost unknown after a particular age, while others 
may and do commonly attack, with equal readiness, persons of 
every age. 

Many are peculiarly frequent in infancy and childhood. In the 
former are to be found hydrocephalus and tubercular meningitis, cy- 
anosis, icterus, sclerema, &c; in the latter, numerous disorders pro- 
ceeding from dentition, strophulus, impetigo and other cutaneous 
eruptions, including small-pox, scarlet-fever, and measles, glandu- 
lar scrofula, mumps, gangrene of the mouth, stridulous and pseudo- 
membranous laryngitis, whooping-cough, convulsions, cholera in- 
fantum, and worms. The period of adolescence is often marked by 
disorders of the nervous and nutritive systems, as chorea, hysteria, 
debility and various derangements of the economy arising from a too 
rapid growth, or from an undue excitement of the sexual propensi- 
ties. Although adult life is less remarkable for its liability to parti- 
cular diseases, than for its susceptibility to all, yet this period is dis- 
tinguished by the frequent occurrence of pulmonary and intestinal 
affections, and those of the genital organs. Neuralgia, melancholy, 
and other forms of insanity, the several varieties of organic and 
inflammatory disease, and hemorrhages, are more prevalent during 
this than any other period of human life. 

In the decline of life, and in old age, if not before, men pay the 
penalty of having overtasked or abused their organs. Most of the 
maladies which disturb that serenity which should mark the even- 
ing of life, are due to a prolonged and habitual neglect of hygienic 
rules. This is especially true of diseases of the generative and di- 
gestive apparatus. The epicurean tendencies of civilized life bring 
on premature exhaustion of these two systems; and, as the oppor- 
tunity has been lost of correcting the evil by the adoption of more 
prudent habits, the consequences of repeated indulgence grow into 
confirmed disease. The slight and temporary indigestion of former 
days is followed by chronic dyspepsia and gout, or by organic dis- 
ease of the stomach or liver ; occasional constipation has become 
habitual and obstinate, and haemorrhoids, fistula in ano, or scirrhus 
of the rectum, succeeds. A little irregularity in the quantity of 
the urine, or slight difficulty in voiding it, is followed by enlarge- 



sex. 77 

ment of the prostate gland, by unyielding stricture of the urethra, 
or by stone. At the same time the brain is liable to be attacked 
with softening, or torn by hsemorrhage, or its proper functions de- 
generate into mental imbecility. The arteries may become ossi- 
fied, producing gangrene of the extremities, or those appalling 
symptoms supervene which arise from thickening of the valves of 
the heart. Many of these affections, it is true, occur in persons 
who have not habitually sacrificed health at the shrine of pleasure; 
some of them, as that variety of catarrh called senile, may depend 
upon unavoidable exposure to the exciting causes of disease, or 
upon the natural decay of the powers of life, but it is, nevertheless, 
certain, that in the great majority of instances a temperate and 
prudent manner of living would have mitigated, if not prevented, 
them. 

Sex. — Although there are a great many diseases to which both 
sexes are equally liable, yet it is evident that each sex must have 
some maladies peculiar to itself, if we only regard those connected 
with the function of reproduction. The womb and its appendages 
constitute not only the anatomical peculiarity of woman, but their 
natural and morbid actions distinguish her from man both in health 
and disease. Hence the disorders which attend menstruation, 
pregnancy, and parturition, have no parallel amongst those of the 
opposite sex. Besides these, females are especially subject to 
tubercular consumption, chlorosis, crural hernia, cancer of the 
mamma, uterus, and ovaries, with neuralgia, hysteria, chorea, and 
the whole catalogue of nervous disorders, some one of which, or 
some derangement of the menstrual function, is perpetually com- 
plicating and obscuring the inflammatory and other affections 
which attack this sex. 

It is sometimes asserted that women who inhabit populous towns 
are alone subject to the diseases which have here been attributed to 
the whole sex, and that in proof of this we shall find women who 
live in the country less subject to nervous affections than men who 
pass their lives in the enervating pursuits of cities. Admitting this 
contrast to exist between the laborious and masculine peasant 
woman of Europe, and the idle and profligate men of the groat 
capitals of that country, it cannot be substantiated in regard to this 

7* ' 



7$ .ETIOLOGY. 

country, for we have not, on the one hand, in our farmer's fami- 
lies a hardy race of females, nor on the other, in our large towns, 
any class of men devoted entirely to sensual gratification; or if 
any, they are addicted, not to the vices which render the nervous 
system more delicate and susceptible, but to those which blunt and 
brutalize it. 

It is said that females are less liable than males to be attacked 
by epidemic diseases, a fact which is attributed to their more re- 
gular habits of life, and their less frequent exposure to the causes 
of these maladies. Men, on the other hand, are more subject than 
women to all those affections which proceed from the direct influ- 
ence of atmospheric vicissitudes, of physical injury, and the seve- 
ral forms of intemperance, such as inflammations, especially of 
the brain, and the viscera of the thorax and abdomen, rheuma- 
tism, renal and vesical calculi, and the scaly forms of cutaneous 
eruption. 

Temperament. — The ancients enumerated four temperaments, 
the sanguine, the bilious, the nervous, and the lymphatic. This 
division will answer for the present purpose, although physiolo- 
gists of modern times scarcely admit its correctness. 

The principal influence of the sanguine temperament consists 
in giving a marked inflammatory character to diseases, and in 
predisposing to plethora and hemorrhages. 

The bilious temperament is said to predispose to affections of 
the digestive organs, and to modify the type of various other dis- 
eases by adding to them bilious symptoms. But the existence of 
this temperament in an individual does not seem to be very sus- 
ceptible of proof, until the actual occurrence of hepatic disease. 
Unlike the sanguine temperament, it is not a physiological con- 
dition. 

The lymphatic temperament, whether properly so called, or not, 
does certainly exist, and is justly charged with creating a tendency 
to mucous and serous fluxes, catarrhs, and passive dropsies, tuber- 
culous and scrofulous affections of the lungs, joints, and skin, &c. 
These diseases have one feature in common : they are all chronic. 
Slowness of evolution is one of the most striking characters of the 
lymphatic or phlegmatic constitution. It is marked by sluggish- 



CONSTITUTION. 79 

ness of mind and inertness of body, as well as by a tedious deve- 
lopment of disease. 

The nervous temperament is the direct opposite of the last, and 
is marked by quickness and susceptibility. It predisposes to all 
the forms of disease which affect the nervous system ; but, more 
particularly, to functional disorders ; to insanity, convulsions, and 
neuralgia, for example. It also modifies the course of other acute 
diseases, and, by the complication of delirium and convulsive dis- 
orders, renders their symptoms more violent, and their issue more 
uncertain. 

Constitution. — The constitution may be strong or weak. A 
robust constitution, is the substantial representative of perfect 
health, and cannot, therefore, be said to predispose to disease, but 
on the contrary, must offer the strongest possible resistance to 
morbid causes. But, on account of the very energy with which 
all the vital actions are performed, when once a person of strong 
constitution becomes affected with disease, these very actions, in 
their perverted state, are executed with singular vigour; in other 
words, the diseases of a strong constitution are also strong, and 
prone to assume the inflammatory type. 

Delicate, or feeble constitutions, on the other hand, are more 
susceptible of injurious impressions, and react less powerfully un- 
der them. They are easily prostrated and exhausted, unable to 
offer much resistance either to the disease, or to the treatment re- 
quired to cure it; and, indeed, they are peculiarly subject to latent 
forms of disease, to those which run their course of structural dis- 
organization, without betraying themselves by distinct symptoms, 
and, consequently, without inviting the interposition of medical art. 
If the diseases of the robust are more violent, they have also more 
strength to overcome; if those of the feeble are apparently mild, 
they are not so in proportion to the ability of the patient to sustain 
them. It is a vulgar error to suppose that a certain delicacy of 
constitution is of itself favourable to longevity. Without that pru- 
dence which a consciousness of danger inspires, the feeble would 
not survive. The robust perish because they are unconscious of 
the dangers which perpetually surround them. 

One of the effects of modern civilization, is the increase of the 



80 , .ETIOLOGY. 

average duration of life. It cannot be doubted that a large pro- 
portion of this increase is owing to that of the number of feeble 
children, now preserved by means of the additional physical com- 
forts which have been enjoyed by each successive generation, for 
the last two centuries. The aggregate of life is indeed greater 
than formerly, but individual examples of vigour are more rare, 
and probably the sum of physical force is less for the same popu- 
lation. 

Idiosyncrasy is a peculiar susceptibility to, or immunity from, 
certain diseases, on the part of an individual. It has, indeed, a 
wider signification, including nearly all personal peculiarities, and 
amongst them such as relate to the action of medicines. The term 
is frequently applied to acquired peculiarities, but ought to be re- 
stricted to those implanted by nature. The hemorrhagic idiosyn- 
crasy is one of the most remarkable ; by preventing the arrest of 
hemorrhage, it has made dangerous, and even fatal, such slight 
injuries as the bite of a leech, and the extraction of a tooth. Cer- 
tain remarkable cases of bloody sweat, recorded by Boerhaave, 
Boivin, and others, appear to belong to this class of hemorrhages. 

Certain articles of food cannot be eaten by some individuals 
with impunity. The most common of these are members of the 
molluscous tribe, such as crabs, lobsters, and especially the salt- 
water muscles, so much esteemed in Europe, and which frequently 
produce an attack of urticaria, or of coma, resembling narcotism. 
On the other hand, there may be an apparent insusceptibility to 
several diseases, to small-pox and vaccinia, for example ; but it has 
been remarked, that some persons who at one period cannot, be in- 
oculated with these diseases, readily contract them subsequently. 

One or two peculiarities in reference to therapeutical agents may 
here be mentioned. The exciting and harassing effects of opium 
and its preparations, and the violent strangury sometimes following 
the external use of cantharides, are familiar instances; but there 
are others which no analogy would lead us to anticipate. A medi- 
cal friend of the writer cannot even smell a bottle containing syrup 
of ipecacuanha, much less a package of this drug in powder, with- 
out suffering a profuse watery discharge from his nose and eyes, 
and a swelling of these parts, which lasts for several days. 



HABITS. FOOD. 81 

Habits of Life and Profession.— These are amongst the most 
powerful of the causes under notice, and may be considered toge- 
ther, inasmuch as the habits of an individual are determined chiefly 
by his ordinary pursuits. Those which require exercise in the 
open air are most likely to induce inflammatory disorders, while 
such as are consistent only with a sedentary life dispose to affec- 
tions of a lymphatic type; and if conjoined, as they frequently are, 
with continued mental application, they occasion congestion of the 
brain and epistaxis ; and if with excessive indulgence in eating and 
drinking, they bring on general plethora, cutaneous diseases, and 
derangement of the digestive and urinary apparatus. They very 
commonly, also, give rise to haemorrhoids and fistula in ano. 

Particular' employments occasion particular diseases; those who 
ride much on horseback are liable to hernia ; singers, and all who 
use the voice excessively, to affections of the larynx ; housemaids, 
in England, to a particular disease of the bursas of the knee-joint ; 
chimney-sweeps, in that country, to a variety of cancerous disease 
of the scrotum ; bakers, to rheumatism ; and workers in metals to 
several forms of poisoning. But these subjects can only be alluded 
to in a general way, in an elementary treatise like the present. 

Food and drink. — The effects of insufficient food are too well 
known to need description here. Debility includes them all, for it 
invades every function of the economy, whether organic or mental. 
If, as Bichat defined it, " life is the sum of the powers that resist 
death," and if disease be only the instrument of death, of course 
whatever enfeebles life, predisposes to disease. The ravages of 
famine in besieged towns, and the epidemic maladies which so 
often desolate the lower classes of the Irish, denote this influence 
on a large scale. The type of these disorders is adynamic. Im- 
perfectly nutritious food is also productive of disease. A too 
copious, or too nutritious diet may prove injurious, either by over- 
stimulating the digestive organs, and ultimately exhausting them, 
or by immoderately increasing the amount of blood, fat, or muscle. 
Excessively corpulent persons arc exposed to death from suffoca- 
tion, whenever an accidental cause diminishes their already feeble 
powers, or from apoplexy upon any unwonted exertion or excite- 



82 .ETIOLOGY. 

ment ; indeed, when attacked by almost any form of disease, they 
offer but little resistance to its progress and fatal termination. 

The diseases of the poor and of the wealthy, when contrasted, 
show the influence of opposite modes of living. The former are 
for the most part, those of debility, as typhus fever, scurvy, scro- 
fula, and dysentery ; while the latter generally proceed, in the 
first instance, from over-stimulation, and include gout, gravel, 
dyspepsia, hypochondriasis, apoplexy, and chronic cerebritis. 

Although water may, as a general rule, be the safest, or the 
only safe drink, it can be used intemperately as well as alcohol ; 
and if its taste and primary effects were as pleasant as those of 
fermented and distilled liquors, it would be hardly less pernicious 
in its effects. When drunk immoderately it impairs digestion and 
nutrition, and reduces the system to a condition so far resembling 
that proceeding from spirituous drinks, as to render it an easy 
prey to the attacks of every severe disease, by despoiling it of 
its elasticity and vigour. An habitually intemperate use of wine 
and alcoholic liquors leads to consequences which, unfortunately, 
are too familiar to require a detailed description. The drunkard, 
besides suffering from delirium tremens, and being corroded by 
disorders of the stomach, liver, and brain, directly excited by his 
brutal vice, is in imminent danger of perishing from causes which 
are harmless to other men. He is always amongst the first vic- 
tims of epidemic disease, and when attacked with sporadic dis- 
orders, his treatment is embarrassing and unsatisfactory, for he 
can neither support disease, nor the treatment necessary for its 
removal. 

Coffee and tea can hardly be said to be independent causes of 
disease, except when they act upon persons otherwise morbidly 
disposed. The former, when properly made, improves digestion, 
and promotes cheerfulness, but when taken in the evening, is very 
apt to prevent sleep ; when made so as to extract the bitter prin- 
ciple of the berry, the decoction of coffee becomes heating, exciting, 
and astringent, disordering the stomach, occasioning headache, 
and confining the bowels. Tea, when used in moderation, espe- 
cially black tea, is equally a gentle stimulant io the nervous sys- 
tem ; but green tea, when imprudently taken, deranges the system 



DRESS. 83 

much more than coffee. It not only dispels sleep, but produces a 
restlessness, and a sense of tension in the nerves, which is almost 
intolerable, and by degrees brings on dyspepsia, attended with re- 
markable peevishness, and sourness of temper. 

Dress is by no means unimportant, as creating a predisposition 
to disease. Garments which leave a portion of the surface of the 
body uncovered, expose to attacks of rheumatism, catarrh, pneu- 
monia, and the other inflammatory affections produced by atmo- 
spheric vicissitudes. The prevalent fashion of leaving the bosoms 
and arms of little children bare, is thought by some physicians to 
render them more liable to croup and thoracic affections generally. 
Too warm clothing disposes to very similar consequences, by pro- 
moting unduly the cutaneous transpiration, rendering the surface 
of the body more sensitive to cold, and so reducing the strength 
as to increase the susceptibility to all injurious impressions. Warm 
beds act much in the same way, and in females are a prolific 
cause of excessive menstruation and leucorrhoea. They are said 
also to predispose to calculous disorders, by augmenting the per- 
spiration, and of course, concentrating the urine. Of this effect 
some doubt may be entertained. Warm cushions incline to the 
disorders of females just mentioned, besides which they pretty 
surely give rise to piles. 

Garments often act injuriously by compressing different parts, 
by thrusting organs from their places, or interfering with their pro- 
per functions. Tight corsets are remarkably mischievous in this 
way ; they compress the stomach, and prevent its reception of 
sufficient food, or the digestion of what it receives ; they so hamper 
the liver as to change it from a flat to a conical figure, and imprint 
upon its surface the outline of the ribs ; they prevent the descent 
of the diaphragm, and the expansion of the chest, and thus enfeeble 
the lungs, and displace, even when they do not disorder, the heart ; 
they debilitate the muscular walls of the abdomen, and interfere 
with the passage of food through the bowels, thus giving rise to 
constipation, with all its consequences ; they press upon the gravid 
uterus, and sometimes produce abortion, or failing of this effect, 
may occasion some malformation of the foetus, which reduces it to 
the class of monsters ; and finally, they arrest and destroy all that 



84 AETIOLOGY. 

development of the mammas and upper part of the chest which 
is not only one of the greatest of female charms, but which is of 
the highest importance to the female as a mother. Tight cravats 
and other garments compressing the neck, tend to produce conges- 
tion of the brain and apoplexy, bleeding at the nose, and feebleness 
of vision ; tight garters cause oedema and varicose veins of the 
legs ; and small shoes deform the toes of growing children, giving 
rise to corns and bunyons, impede the freedom of the general 
circulation, and, in those who are predisposed to the disease, may 
bring on a fit of the gout. 

Fatigue, when excessive, although it cannot be said to bring on 
any particular disease, renders the system very susceptible to what- 
ever morbid influences may be present, and imparts to the disease 
then contracted, an unusual degree of gravity. The exhaustion pro- 
duced by loss of sleep is equally dangerous, and when, to many 
nights of constant watching, is added anxiety or distress, the ner- 
vous system acquires an unwonted irritability, and is very apt to 
manifest distinct disease. Over-indulgence in sleep, on the other 
hand, diminishes the activity of all the functions; it stupefies the 
mind, enfeebles the muscles, and hinders the discharge of excre- 
mentitious matters from the body, thus favouring plethora with all 
its consequences, including congestion, and other disorders of the 
brain. It has been noticed, that attacks of apoplexy and of gout 
are more liable to come on during sleep, than at any other time, 
and it is of still more general notoriety that early risers enjoy a re- 
markable immunity from these, and indeed most other maladies, 
and are more apt than other persons, to reach a good old age. 

Like fatigue, convalescence from disease induces a state of debi- 
lity favourable to the impression of morbid causes. This is a mat- 
ter of daily observation, and is the motive of those precautions 
which it is customary to recommend to the convalescent patient. 
It is still more strikingly seen in the readiness with which such 
persons are attacked on the first appearance of epidemic maladies. 

Previous Disease. — With the exception of those affections which 
occur but once in the same individual, nearly all others huve a ten- 
dency to return. Thus, it is very uncommon for a person to ex- 
perience only one attack of spasmodic croup, gout, epilepsy, hyste- 



POSITION OF ORGANS. 85 

ria, &c. Every organ that has been once inflamed, is peculiarly 
liable to repeated attacks of inflammation. The first of these may 
be said to predispose to those which follow, because the original af- 
fection has so far modified the structure of the organ, as to render 
it more susceptible than at first, to disturbing influences. But in 
gout, epilepsy, &c, one attack can with no more propriety be said 
to cause the succeeding one, than one paroxysm of intermittent 
fever, that which follows it. The aggregate of the paroxysms con- 
stitutes the disease. Each one, after the first, depends as directly 
upon some cause in the system, as did the very first itself. 
Every fit of gravel, or of bilious colic, is the immediate con- 
sequence of the formation of a renal or biliary concretion, and its 
arrest in the ureter, or gall duct ; the several fits have no other 
connexion than through the medium of this common cause. 

The Position of Organs, fyc. — It is probable that amongst un- 
civilized nations, the structure of the human organism is perfect in 
reality, as well as in plan, but this is far from being the case in 
countries where art has supplanted nature to a great extent ; for 
we there find certain maladies evidently depending upon the ana- 
tomical relations of organs, upon their congenital or acquired de- 
viations from the normal type, or upon the manner in which their 
functions are performed. Thus, the natural position of the uterus 
exposes it to be readily displaced ; the manner in which the testi- 
cle descends, and the anatomy of the groin, predispose to hernia ; 
the form of the aortic arch renders it liable to aneurism ; the soft- 
ness of the cerebral tissue, and the delicacy of the walls of the ar- 
teries supplying it, account, in part, for the frequency of apoplexy. 
So, too, congenita^ deformities of the chest develope cardiac and 
pulmonary diseases ; narrowness of the pulmonary artery is one 
of the causes of cyanosis ; that of the aorta tends to produce 
disease of the heart ; imperforation of the hymen may cause the 
menstrual fluid to distend the womb, &c. 

The exaggeration of any function predisposes to disease. The 
overtasked or harassed mind is a ready prey to insanity ; all the 
secernent organs are prone to organic disease, when the quantity 
of their discharge becomes excessive; and such discharges, by in- 
ducing debility, expose to various forms of disease. The pregnant 






86 iETIOLOGY. 

and parturient states are the indirect sources of a large number of 
serious or vexatious disorders. 

Sympathy, — When an organ is observed to be usually affected 
on the occurrence of disease in some other part, the former is said 
to be sympathetically disordered, and thus, by sympathy, one dis- 
ease predisposes to another. There is, indeed, a general and re- 
ciprocal dependence of all the organs upon one another ; so that a 
derangement can scarcely take place in one, without its being re- 
sponded to by all the rest. But this is not the point at present un- 
der consideration ; it is, rather, the liability of two or several 
organs, to be habitually affected in succession, by a disease com- 
mencing in one of them. It has been observed, that those which 
are conjoined in the performance of a particular function, are very 
apt to display morbid sympathies, as the uterus, the ovaries, and the 
mamma? ; the intestine and the liver ; the lungs, and the respiratory 
muscles, &c. ; and in this way, injury of either one of the double 
organs is apt to induce disease in the opposite one. It has also 
been noticed, that distant parts of the same structure sympathize; 
as the lower bowels and sphincter ani with the stomach, in nausea 
and vomiting ; the mucous membrane of the nose and tongue, with 
disorder of the intestinal canal ; the orifice of the urethra, with irri- 
tation of the pelvis of the kidney or ureter, by a calculus. Organs 
which lie in contact, suffer from each other's diseases, either by the 
actual extension of these latter from one to the other, or by their 
exciting functional disturbances in the organ secondarily affected. 
An example of the first sort is the extension of inflammation from the 
lung or pleura of the right side, to the liver, and of the second, the 
occurrence of vomiting and constipation in peritonitis. Finally, there 
appears to be a sympathy between some parts which have no func- 
tional community, nor any direct anatomical connexion, as between 
the parotid gland and the testis, the liver and the right shoulder, 
the brain and the stomach, &c. 

Attempts to explain these various phenomena, and even to class 
them, have failed of success. Many of those belonging to sensa- 
tion and motion have of late years been pretty satisfactorily shown 
to depend upon nervous connexions between distant parts, not by 
direct communication, but, indirectly, through the medium of the 



SYMPATHY. 87 

spinal marrow ; yet by far the most numerous cases of sympathetic 
disorder still continue to be unexplained, and are, in all probability, 
inexplicable. 

There is another form of morbid dependence which ought, per- 
haps, to be included under the general title of sympathy ; this is the 
tendency of an organ to become diseased in consequence of the 
disorder of another organ of analogous, but not identical function. 
An example of this is furnished by the mutual dependence of the 
liver and lungs, both of these organs being intended, as physiolo- 
gists suppose, to remove carbon from the blood ; and another by 
the frequent coincidence of hepatic and cardiac maladies, owing it 
may be presumed, to the fact that so large a quantity of blood passes 
through both the liver and the heart, that one cannot be curtailed 
of its office without overloading the other. 



CHAPTER III. 

EXCITING CAUSES. 

SECTION I. 

GENERAL AND SPECIAL EXCITING CAUSES. 

Exciting causes, it was stated, may be divided into general, 
special, and specific. The first of these divisions includes all those 
which directly develope disease without determining its nature or 
seat, and consequently all which have been enumerated as pre- 
disposing causes; for when their action, instead of being protracted 
and feeble, is sudden and energetic, they not only promote but 
actually determine some morbid state. In this manner the ordinary 
denominations of causes have sometimes to be reversed. Marsh 
miasm is of all other causes one of the most direct and specific in 
its action, and bodily fatigue one of the least precise, for it does not 
dispose to one disease more than another, yet in the following ex- 
ample quoted from Dr. Copland, the action of the specific cause 
would never have been made manifest but for the intervention of a 
predisposing, now become an exciting, cause. " Between twenty 
and thirty persons were exposed all night, without cover, to the air 
of one of the most fatal sources of miasmata furnished by a warm 
climate, during the unhealthy season, but were soon afterwards 
removed to sea — far from any further exposure to this specific 
cause. They continued well for six or seven days, when about 
half their number experienced great fatigue. All these were, nearly 
simultaneously — on the following day — seized with remittent fever; 
whilst those who had not been subjected to this consecutive cause, 
with the exception of two who were not attacked till several days 
subsequently, entirely escaped, although all had been equally ex- 
posed to the specific cause of that form of fever." 



EXCITING CAUSES. COLD. 89 

Another illustration of the difficulty of separating predisposing 
from general exciting causes, and an evidence that these latter are 
correctly named, may be found in the fact that in the histories 
which we possess of individual diseases, the separation is not often 
attempted, nor often successfully; and also that for many affections 
a catalogue of causes is given including nearly all which have been 
discussed in the preceding pages. Without, therefore, again treat- 
ing of all of these in their new aspect, it will still be proper to 
allude to one or two. 

Cold. — A temperature below the freezing point of water, if it act 
for a considerable length of time, will destroy life, and if applied to 
a part for a shorter period will benumb or paralyse it. Cold evi- 
dently causes the solids to contract, and in that way diminishes the 
amount of blood in the vessels, and the generation of animal heat. 
When the whole surface of the body is exposed to it, the internal 
organs become gorged with blood, their functions are impeded, the 
brain acts feebly, the sensibility is blunted, and death is imminent. 
When, however, the cold is less intense, or operates for a shorter 
time, reaction takes place in the affected part; redness, pain, and 
heat succeed to pallor and numbness, and there may ensue a 
gradual return of the part to its usual condition, or the development 
of some form of inflammation. It seems probable that internal in- 
flammations, when caused by cold, are due to its influence upon the 
surface of the body, where it not only drives the blood inwards, 
congesting the internal organs, but arrests the cutaneous exhalation, 
and thus causes excretory matters to be retained in the system. 
Whatever organ happens to be the weakest or most exposed at the 
time is most likely to suffer first. 

If cold be applied to one portion only of the surface, the nearest 
organ will be most in danger. The throat, lungs, and large joints, 
are most readily affected by this cause ; the former in consequence, 
probably, of the upper part of the trunk perspiring more freely 
than any other part of the body ; and the last, it may be conjec- 
tured, because they are either not well covered by muscles, or be- 
cause the fibrous tissues investing them contain but little red blood, 
and therefore generate but little heat. The retreat of the blood 
from the surface and its accumulation in the abdominal organs, 

8* 



90 AETIOLOGY. 

appear to explain the sudden attacks of diarrhoea which cold and 
dampness produce in persons of feeble constitution, and in those 
labouring under depression of spirits or bodily fatigue. The marked 
increase in the urinary discharge on the approach of cold weather 
may be referred to the same source. But exposure to a low tem- 
perature, and especially getting the feet wet, arrests at least one 
internal secretion, the menstrual. How happens it that internal 
congestion favours the loss of fluids by the bowels, but suspends 
the flow of blood from the uterus? Writers inform us that a cer- 
tain degree of congestion in a part arrests its secretion, and that a 
somewhat greater degree augments the discharge, but as we have 
no means of determining whether the congestion of the bowels 
which favours diarrhoea is greater or less than that of the womb 
which suspends the menstrual flow, the explanation is not very 
satisfactory. The truth is simply this : observation teaches that 
the condition of the system most favourable to the regular flow of 
the menses, is that of perfect health, in which the temperature of 
the body is moderate and equable, and the circulation everywhere 
of the same activity ; observation also teaches that a similar con- 
dition of the circulation and of animal heat is most conducive to the 
normal action of the bowels ; and finally that cold, which breaks 
up the order of favourable circumstances, substitutes in each case 
a morbid for a health r ul result. Beyond this, our knowledge does 
not extend ; it does not enable us at present to reduce the two dif- 
ferent and apparently contradictory phenomena under the same 
law. It is well, therefore, not to accept as explanations of patho- 
logical facts, many phrases which are current as such, but which 
really explain nothing ; but rather to study attentively the natural 
sequence of phenomena in each particular case, and having es- 
tablished their dependence upon one another, rest contented with- 
out attempting violently to force them into subordination to some 
general law. 

Pain and Mental Emotion. — The brain is not only the instru- 
ment of the mind, but it presides over, and controls the functions 
of all the other organs. Its own disorders can hardly fail, there- 
fore, to affect them. This influence has been observed in all ages, 
and is the source of those theories which have designated the liver, 



MENTAL EMOTION. 91 

the stomach, and the spleen, as the seat of the passions. Strong 
emotion may not only suspend or pervert particular functions, but 
is even capable of destroying life, by arresting the action of the 
heart. When disease is already present, as, for example, soften- 
ing or habitual congestion of the brain, tubercles of the lungs, 
aneurism, &c, its effects are still more to be dreaded. Every one 
must have felt how suddenly digestion may be suspended by disa- 
greeable tidings or events, and will be ready to understand the 
pernicious influence of habitual grief, upon the functions of the 
digestive organs. Under its corroding blight, the skin loses its 
freshness, and grows dry and yellowish ; owing to the derange- 
ment of the liver, the bowels become confined, and their habitual 
constipation is apt to be followed by permanent disease in their 
lower portion, and by congestion of the brain, with all its con- 
sequences. 

Terror is very apt to bring on miscarriage, or suppress the 
menses, or excite sudden diarrhoea, or frequent voidance of urine. 
High-wrought anxiety may have the same effect. An eminent 
lecturer of this city was in the habit of relating to his class an 
illustration of this fact. He was on duty as medical officer during 
one of the first naval engagements of the last war with England. 
From the time when the hostile vessel was first made out, until the 
commencement of the battle, he remarked that both officers and 
men were running, at every instant, to the ship's side, to empty 
the bladder, so intense was the anxiety and excitement amongst 
men who had never before met an enemy in fight. 

Anger often brings on a convulsive attack ; and, occasionally, 
when smothered, has been known to produce universal jaundice in 
a few minutes. The fact is too familiar to need illustration here, 
that insanity frequently follows close upon exaggerated mental 
effort, and especially upon violent mental emotion, whether terror, 
grief, or joy. 

A special exciting cause, it has been intimated, is one which, 
while it immediately precedes the development of disease, and 
gives to it a definite form, is not the only one from which the re- 
sulting disease may arise. It may be added, that most of the 
causes, of this class, operate without the aid of any evident pre- 



92 ETIOLOGY. 

disposition. It includes mechanical and chemical causes, and 
poisons. 

Mechanical Causes. — These are innumerable. It will be suffi- 
cient to mention some examples of them. Such are all kinds of 
instruments used to wound or otherwise injure the body ; falls 
against hard substances ; ligatures, or other means of compression, 
by which the circulation, or the passage of the air or other mat- 
ters through their respective canals is impeded ; obstacles to the 
entrance of the air into the body, whether this result from immer- 
sion in water, carbonic acid gas, or any other irrespirable medium ; 
obstructions within the various canals of the body, as foreign sub- 
stances in the oesophagus, or windpipe, the nasal or auditory pas- 
sages, the vagina, urethra, or bowels ; a collection of hardened 
fasces in these latter ; the arrest of a gall-stone in the biliary ducts, 
of a calculus in the ureter, or of a parasitic animal, or worm, in 
either. 

Chemical Causes. — These are also very numerous, and include 
all which destroy the natural organization of a part by virtue of 
chemical affinity. Metals, and other substances, at a high tempe- 
rature, boiling liquids, and caustics, whether solid or liquid, acid, 
alkaline, or saline, act in this manner. Some of them, like corro- 
sive sublimate, and the arsenical preparations, from their usually 
producing their effects after being taken internally, are ranked 
amongst the poisons. Taken in this manner they produce disease 
in one of two ways. If in large doses, they prove injurious or 
fatal by their direct action upon the tissues of the stomach, which 
they destroy chemically ; if in smaller doses, and frequently re- 
peated, they prove fatal by injuring one function after another, 
until not enough are left unimpaired to sustain life. 

Poisons. — It is difficult to frame a definition of these agents. 

© 

That of Fodere is sufficiently precise in practice. He considers 
poisons to be those substances which are known by physicians to be 
capable of altering or destroying, in a majority of cases, some or 
all of the functions necessary to life. They are usually divided 
into irritants, narcotics, narcotico-acrids, and sept.ics. " The 
class of irritant poisons," says Christison, "comprehends both 
those which have a purely local irritating action, and likewise 



POISONS. 



many which also act remotely, but whose most prominent feature 
of action is still the inflammation they excite wherever they are 
applied." The chemical agents already mentioned, cantharides, 
iodine, chlorine, &c, are of this class. Narcotic poisons, on the 
other hand, produce little or no effect upon the part to which 
they are applied ; but act through the medium of the nervous sys- 
tem, occasioning various perversions of the intellect, sensibility and 
muscular power, and generally threaten or destroy life by inducing 
asphyxia. The most prominent amongst them are opium, hyos- 
cyamus, prussic acid, and their preparations, to which may be added 
carburetted and sulphuretted hydrogen gases. 

Narcotico-acrid poisons include those which possess a double 
action ; the one local and irritating, the other remote and upon the 
nervous system, by which latter, indeed, they generally prove fatal. 
Of this extensive class may be cited belladonna, stramonium, to- 
bacco, conium, aconite, strychnine, alcohol, and ether. Certain 
vegetable effluvia, which occasion disease, find, perhaps, a more 
appropriate place along with the two last classes of poisonous 
agents, than elsewhere. An atmosphere loaded with the odorous 
principle of the jessamine, the tuberose, the hyacinth, the lily, &c, 
produces headache, nausea, vertigo, and even syncope, when con- 
fined within close apartments. During the season of roses, and at 
the hay-harvest, not a few persons suffer from coryza, with fever, 
which goes under the name of hay or rose fever. 

Septic poisons, or those which are generated by putrefaction, 
give rise to affections which are characterized by a typhoid or ady- 
namic state, are often complicated with gangrene, and generally 
tend to a fatal issue. The pernicious matter may be introduced 
into the economy along with the food, as in unsound meat or 
damaged flour; or through the lungs, as in camps, besieged towns, 
and crowded military hospitals; in graveyards and churches, when 
soil saturated with the results of putrefaction is upturned, or long- 
closed burial-vaults are opened ; or it may be inoculated through 
a wound, as so frequently happens to those engaged in anatomical 
studies. Retention of the urine and foeces has some analogy with 
the morbid causes just considered. When foocal matters accumu- 
late in the bowels, besides disposing to ulceration and perforation 



94 ETIOLOGY. 

of their walls, the more fluid parts are absorbed, and may even 
communicate a foetid odour to the breath and perspiration, as well 
as dispose to typhus fever. This is strikingly the case during pro- 
tracted abstinence, or refusal to take nourishment, among the in- 
sane. Suppression of urine, as is well known, is apt to be followed 
by fatal coma. 

Venom, a liquid secreted by an apparatus peculiar to certain ani- 
mals, and which serves them for attack or defence, must be ranked 
among the exciting causes of disease. Its action is usually very 
prompt, and may either be limited to the part stung or bitten, or 
involve a limb or even the whole body. The rattlesnake and the 
copper-head, amongst serpents, the hornet, the wasp, and the bee, 
among insects, are the well-known representatives of the venomous 
tribes in this country. 



SECTION II. 

THE SPECIFIC CAUSES OF DISEASE. 

By specific causes are meant those which, not only like what 
have been already considered, engender distinct diseases, but also, 
and unlike them, are the only causes of the maladies which follow 
their application respectively. Such, at least, is a strict definition 
of the phrase, derived from the phenomena of paludial fevers, and 
inoculable diseases, but some affections which ordinarily arise 
from a particular cause, and from that alone, do in exceptional 
cases, proceed from another cause. Thus, several diseases whose 
rule of propagation is from individual to individual, do in excep- 
tional instances appear to be spontaneously generated, and still 
more, upon the other hand, those which seem to be of atmospheric 
origin, are at times unequivocally disseminated by contagion. For 
the better understanding, then, of the present subject, we shall 
consider the whole field in which the action of specific causes is 
more or less constant and apparent, including the general laws of 
endemic and epidemic diseases, and as a preliminary to that dis- 
cussion, make a few remarks upon infection and contagion. 



INFECTION. 95 

Infection. — By some writers, the terms infection and contagion 
are used as synonymous, and undoubtedly, if reference be had to 
the etymology of the words, this usage is, to a certain extent, cor- 
rect. The Latin word inficere signifies to corrupt or vitiate, and 
hence infection includes every means by which the system may be 
corrupted or vitiated ; hence also contagion, which merely implies 
contact, must in its pathological sense, indicate corruption or 
vitiation of the system by contact with a person previously dis- 
eased. In other words, contagion is a mode of infection. 

But, since it must be admitted that some maladies are generated 
spontaneously, while their further propagation by contagion, is 
altogether accidental ; and that certain others are in nearly every 
instance disseminated by contagion, while their origin from atmo- 
spheric or other non-animal sources is altogether exceptional, it 
follows that to include both modes of propagation in the same 
description, is to unite what nature has divided. We shall there- 
fore commence by giving some account of infectious agents proper, 
and of the laws which govern their action. 

These agents consist almost entirely of decayed or diseased 
organized substances, and of animal emanations or secretions. 
Some of them have been partially referred to under the head of 
poisons. They are found to exist most abundantly in marshy and 
alluvial soils, in slaughter-houses, common-sewers, dissecting- 
rooms, graveyards, and in those places where a large number of 
living persons are crowded together; particularly if the effluvia of 
their excretions taint the atmosphere. Such places are called 
centres ox foci of infection, because from the morbid influence there 
concentrated, disease spreads in every direction. These sources of 
infection are not at all times endowed with equal energy ; their 
action is most powerful in tropical climates, and during the 
summer and autumn in temperate regions. 

The insalubrity of the neighbourhood of marshes, particularly 
on the side exposed to the wind sweeping over their surface, has 
been known in all ages, and its reality proved by the restoration 
of the sickly district to health, on the water of the marsh being 
carried off by drainage. In fact, wherever a rich, wet, and low soil, 
abounding with vegetable and animal matters undergoing decay, 



96 ^etiology. 

is exposed to a powerful sun, after repeated irrigations or inunda- 
tions, remittent and intermittent fevers will prevail, and of a more 
malignant type as the heat is more intense. It is probably- 
owing as well to the vast number of the exuviae of insects which 
crowd the salt-water marshes, as to the high temperature of the 
air, of intertropical countries, that the mortality of the diseases oc- 
casioned by them is owing. But even in these situations it is not 
so much during the heat of day, as after nightfall, that the infec- 
tion is active, a circumstance which has been plausibly explained 
by supposing that the deleterious emanations being mixed with the 
moisture of the air, are kept diffused through it during the day, but 
when the coolness of evening succeeds, descend to the lower strata 
of the atmosphere, where they of course act with redoubled vigour. 

When the infectious locality is of small extent and so situated 
that the effluvia accumulate within it, their power of generating 
disease is rendered so intense as sometimes to prove fatal almost 
immediately. This is especially true of emanations from putre- 
scent matter, such as is collected in sewers, privies, &c, but almost 
as rapid an action has been observed in the case of paludial exha- 
lations. Pringle, in his work on diseases of the British army in 
Holland, relates that among the foraging parties sent out early in 
the morning, when the meadows and marshes on each side of the 
road were covered with a thick fog of offensive smell, several men 
were so suddenly taken with a phrensy, as to throw themselves 
from off their trusses into the water, imagining they were to swim 
to their quarters. But in general, centres of malarious infection 
are not of so malignant a nature. Their influence diminishes ra- 
pidly with the distance from them, even upon the surface of the 
earth, and still more rapidly above this level ; on the other hand 
it is augmented wherever anything tends to arrest and confine the 
vitiated air, such as cellars, the courts and lanes of towns, and 
narrow valleys. 

A high temperature tends to produce malarious diseases, chiefly 
when the air is loaded with moisture, a fact which goes far to favour 
the opinion that the infectious cause is something substantial, which 
cannot be supported and carried about in so rare a medium as dry 
air. It is further corroborated by another fact, viz., that a calm state 



ANIMAL EFFLUVIA. 97 

of the atmosphere is most favourable to the prevalence of malarious 
disorders, while a strong wind, especially if it be cold, abates or even 
puts an end to them. It may be added to these illustrations that a 
wind blowing over an infected district may cause the prevalent 
disease to be experienced in regions where it was before unknown; 
that if a hill be situated in the direction towards which the wind 
sets steadily for some time, the people living upon the side nearest 
the infected locality are more likely to suffer than those who in- 
habit the intermediate country, and the residents on the further side 
of the hill may escape the noxious influence altogether. In the 
same manner walls, houses, running streams, long and winding 
streets, &c, have been known to form barriers to the progress of 
infectious disease in one or more directions. 

Animal secretions and emanations have a just claim to be 
ranked amongst the infectious causes of disease, because, although 
their effects are not absolutely uniform, yet they generally give 
rise to maladies capable of propagating their like by means of con- 
tagion. It is, however, to be remarked that the particular form of 
disease generated in crowded receptacles of human beings, — jails, 
hospitals, &c, will depend very much upon the nature of the pre- 
disposing and concurrent causes. The most usual form is typhus 
fever, and here the concurrent causes are generally poverty and 
unnutritious food ; another is dysentery, which commonly requires 
cold and moisture, along with unripe fruit, for its* production 
amongst soldiers and other large bodies of men ; puerperal fever, 
and purulent ophthalmia in children's hospitals, depend upon some 
occult cause, as well as upon crowding the wards appropriated to 
the subjects of these diseases. 

A singular example of the effects of crowding, and one showing 
their dependence upon a very slight change of circumstances, is 
furnished by Dupuytren, in his report upon the fatal malady which 
prevailed in his wards at Hotel Dieu. The usual number of pa- 
tients in them was two hundred, and then there was no unpleasant 
odour, nor any sign of infectious disease. But no sooner had the 
number increased to two hundred and twenty, or more, than a pe- 
culiar fcetor became perceptible, and many of the patients fell vic- 
tims to hospital gangrene and adynamic fevers. 

9 



98 .ETIOLOGY. 

The active principle of marsh miasm, as well as of that given 
off by human bodies, is unknown. The air collected from the sur- 
face of certain stagnant swamps and lakes has been found to con- 
tain carbonic acid, carburetted hydrogen, and nitrogen. Sulphu- 
retted hydrogen has also been detected in the water of both salt 
and fresh marshes, and in the air in contact with them, by Dr. 
Gardner, now of Philadelphia. But these results are far from 
being uniform. The vapours of the putrid waters of Fuentes, of 
the rice fields of Lombardy, and of the Campagna of Rome, have 
been found identical in composition with the most salubrious air, 
or rather it would be more correct to say, that such is the result 
of chemical analysis ; but it does not by any means follow, that 
there may not have been material differences in the air of the places 
mentioned, although the means of analysis employed were inade- 
quate to their discovery. We are much better entitled to infer a 
difference of composition between mountain air and that of the 
pestiferous fens alluded to, from their palpable effects, than to re- 
ceive as conclusive the results of experiments which may have 
overlooked, or actually destroyed, the virulent principle, minute in 
quantity, but pregnant with pestilence. 

But to return. By condensing the vapours arising in certain 
malarious districts, small portions of mucus, containing animal 
matter, ammonia, and hydrochlorate and carbonate of soda, have 
been obtained. This discovery would appear to countenance the 
hypothesis of Varro, that marshy emanations contain innumerable 
and invisible insects. Dr. Holland has, in our own time, revived 
this hypothesis, which he has illustrated in a style no less elegant 
than ingenious. Some maintain that heat and moisture, followed 
by a low temperature, conditions which do certainly exist in the 
neighbourhood of marshes, are sufficient to account for the pheno- 
mena of malarious diseases ; and however untenable such a posi- 
tion may be, it must be admitted that these conditions of tempera- 
ture and humidity may act as concurrent causes, by diminishing 
the power of the system to resist the influence of the miasm which 
is alone capable of exciting the diseases in question. 

There has been a great deal of discussion, and there is still a 
great deal of doubt, in regard to the manner in which infectious 



MODUS OPERANDI OF MIASMS. 99 

principles invade the economy. It is evident that there are three 
possible modes by which they may obtain entrance ; through the 
skin, the alimentary canal, and the lungs. The cutaneous surface 
may be pretty safely considered as offering a barrier to their pas- 
sage, so long as the epidermis is intact. The experiments of 
Bichat, which appeared to show that the odorous particles of a 
dissecting-room could be taken into the system through the skin, 
so as to be perceptible in the gas discharged from the bowels, are 
open to several objections ; and those of Collard de Martigny, 
which seemed to demonstrate that the poisonous effects of carbonic 
acid gas might be produced by its absorption through the skin, 
have been contradicted by the results of others, conducted in the 
same manner. The mucous membrane of the bowels is protected, 
by its position, from contact with the atmosphere and the morbific 
particles suspended in it, except so far as these latter may become 
entangled in the food and drink ; but there is neither any direct 
evidence of the reality of this mode of action, nor, judging from 
the small quantity of material that could be conveyed in the man- 
ner supposed, any probability in its favour. 

There remain, then, the lungs; and nearly all modern authorities 
agree that it is chiefly through them that infectious agents are in- 
troduced into the economy. It is well remarked by Dr. Copland, 
that upon the respiratory surfaces the air may be said to undergo 
a process of digestion, certain elements or portions of it entering 
into the circulation, and certain others being given off which have 
served their purpose in the economy. This writer, however, con- 
siders that the morbid agents received into the lungs make their 
impression upon the organic system of nerves, and thus lay the 
foundation of the subsequent disease. Without denying the reality 
of this influence, in view of the very rapid effects sometimes pro- 
duced by malaria, and of which an illustration has been given on 
a preceding page, it would appear more worthy of credit that the 
pernicious substance is absorbed into the blood, which it more or 
less quickly vitiates, and thus occasions the subsequent symptoms. 
Two considerations render this supposition probable: the one, that 
in the class of diseases now more particularly under notice, the 
blood undergoes sensible alterations: and the other, that in consti- 



100 -ETIOLOGY. 

tutional contagious affections, properly so called, and which have 
so close an analogy with infectious disorders, it is difficult to ima- 
gine any other mode of origin than through a change in the circu- 
lating fluid. 

Contagion. — Contagious diseases, strictly so called, that is to 
say, which cannot be traced to any other source than communica- 
tion mediate or immediate with persons already attacked by them, 
and which cannot be referred to any atmospheric or other external 
cause, or combination of causes, but only to pre-existent cases of 
the same kind, have been well characterized by Gaubius. " As 
in their origin, so in their natures, they greatly differ among them- 
selves, and every one possesses its own peculiar powers, by which, 
when they have come into bodies favouring their action, through 
their proper channel of communication, they every one procreate 
their own distinct form of disease by a constant law, no otherwise 
than the semina of plants and animals, received into fit places, 
evolve their determinate species. Hence, a particular disease arises 
from every different contagion." The contagion of small-pox, of 
syphilis, of scarlet fever, of rabies, of pellagra, &c, produces its 
own disease, and no other; it is a specific virus or influence, per- 
petuating a malady always presenting the same essential charac- 
ters. 

Amongst these diseases there are several, which, although their 
ordinary or normal mode of spreading is by contagion, yet, beyond 
reasonable doubt, do sometimes arise spontaneously ; this is the 
case with small-pox, rabies, and glanders, the two last, indeed, 
being only of spontaneous origin in the lower animals, from which 
they are communicated to man. There are others, again, dis- 
tinctly contagious, which, like scarlet fever and measles, are usu- 
ally thought insusceptible of transmission by artificial inoculation, 
and one, primary syphilis, which, so far as we know, arises in no 
case without contact. 

But the degree of contact necessary for communicating conta- 
gious diseases, is not the same for all ; it may be direct or indi- 
rect. It is direct, when the virus is conveyed immediately from 
one person to another; and this may take place in one of several 
ways : 1st, by proximity to the sick person, as in his chamber, 



CONTAGION. 101 

when the air is saturated with emanations from his body. In this 
way, typhus fever and small-pox, and the other eruptive fevers, 
are commonly propagated ; 2d, by direct contact, as in attending 
upon, or sleeping with a person ill of a contagious disorder ; 3d, 
by contact of a fluid containing the specific virus, with the skin or 
mucous membrane, and more certainly, when these surfaces are 
abraded, or the morbid fluid is introduced by inoculation. Rabies, 
vaccine, and syphilis, are communicable in no other manner. It 
is to be remarked, that the vehicle of the virus is different in differ- 
ent diseases. In small-pox, malignant pustule, and syphilis, pus 
is the medium of inoculation ; in vaccinia, either this liquid or the 
serum which precedes its formation in the vesicle; in rabies, the 
saliva ; and the medicine is uniformly the same for each disease. 

Contagion is indirect, when it is effected by substances which 
are capable of imbibing and retaining for a considerable time, not 
only the palpable and contagious virus or morbid secretions of the 
sick, but the invisible emanations from their bodies. 

And here let it be borne in mind, that such substances so impreg- 
nated, communicate the disease by contagion, and not by infection, 
as clearly as the lancet which transfers the contents of a variolous 
pustule to a healthy system, gives the small-pox by contagion. 
This is a point too often overlooked. A cargo of rags from the 
Levant arrives at one of our ports, and on being discharged, creates 
disease in all the neighbourhood of the vessel; if the disease thus 
originating is like one which was prevalent at the place whence the 
cargo came, the rags are a source of contagion. If there is no 
such similarity, or there was no prevalent disease at the Eastern 
port, then the newly-arisen malady must be attributed to the filth 
of the cargo, which is, in that case, a source of infection. This 
distinction, we repeat, is often lost sight of, but it is one which really 
exists, and ought to be insisted upon by all who attempt to study 
the details of the intricate subject before us. 

The materials which are reputed to be most susceptible of preserv- 
ing and transmitting contagious principles, are animal productions, 
particularly woollen and hairy substances, bedding and body-clothes, 
furs and feathers. It is thus, no doubt, that physicians become media 
of contagion, by carrying the emanations of the sick chamber in 

9 * 



102 iETIOLOGY. 

their clothing. A physician of this city, who had been visiting 
a patient ill of small-pox, and worn his cloak in the room, returned 
directly home without unfolding his cloak, and meeting his wife in 
the hall, embraced her as she ran to meet him. In a few days she 
was attacked with small-pox, although there was no case of the 
disease within the knowledge of herself or husband, except the one 
he was attending. Dr. Copland relates a case precisely similar ; 
and many analogous instances might be furnished by the history 
of puerperal fever. Such facts should inculcate the duty of atten- 
tion to those circumstances which impair the energy of the con- 
tagious principle. One of the principal of these is exposure to the 
air. 

It is one of the most singular phenomena connected with conta- 
gious diseases proper, that several of them do not attack the same 
individual a second time, appearing thus in their first attack, to ex- 
haust the susceptibility of the patient to contract them ; such are 
scarlet fever, small-pox, measles and hooping-cough, which are of 
extremely rare occurrence a second time in the same person. It 
is scarcely less surprising, however, that syphilis, which is sup- 
posed to resemble the diseases just mentioned, in so many other 
points, should be unlike them in this, and that a person who 
has once contracted the disorder, so far from enjoying an immu- 
nity from it in the future, is even more likely than ever to con- 
tract it anew. There is, however, so palpable a difference be- 
tween the acute febrile constitutional symptoms of the exanthemata, 
and the local sore of syphilis, that one can readily understand that 
the former indicate a profound and radical modification of the sys- 
tem, capable of subverting its original susceptibility, while no such 
action can be attributed to the latter. It is impossible to conjecture 
whether a first attack of rabies would afford protection against sub- 
sequent ones, for no one has ever yet recovered from the first. 

It has already been mentioned that several, indeed many, dis- 
eases which usually originate from external, atmospheric, or other 
causes, may, under certain circumstances, be propagated by conta- 
gion. A neglect of this consideration has given rise to many of 
the hot disputes which have prevailed, regarding the contagious 
quality of certain diseases, disputes which even now are rife, and 



CONTAGION. 103 

in many places have had a practical bearing upon quarantine regu- 
lations. The question of the contagiousness of a malady is not ab- 
solute ; a disease in its sporadic and mild form may be totally in- 
nocuous to persons who are in constant communication with the 
sick, and yet appear to be highly contagious when many subjects 
of it are gathered together in the same ward or building. This is 
true, to some extent, of the most contagious of all diseases, small- 
pox : the writer has repeatedly seen cases of this affection in the 
wards of the Parisian hospitals where all other diseases were 
treated, without its extension either to the assistants or to the pa- 
tients in the adjoining beds. If then, we were asked, are yellow 
fever, the plague, cholera, &c, contagious, we might safely declare 
that they both are, and are not; that originally and essentially 
they are not, but that when many subjects of any one of them are 
brought together, and measures are not rigorously enforced for 
keeping the air of the apartments occupied by them perpetually re- 
newed, all healthy persons coming within the sphere of their influ- 
ence, will be likely to be attacked. This mode of communication 
is by some writers called infection, but it is clearly one of those 
cases which we have illustrated under the head of mediate or indi- 
rect contagion, one in which the air serves as the medium of con- 
tact. 

Upon this subject, the late Dr. Hosack remarked with character- 
istic good sense: " The visiter or attendant contracts disease from 
one of two sources, either from the filth of the sick room, or from 
a specific so?nething issuing from the body of the sick, the conse- 
quence of the peculiar disease under which he labours. If a per- 
son visiting another ill of the yellow fever or plague, derive his 
disease from the impure atmosphere of the apartment, I ask how 
it happens, in all instances, he contracts the same disease with that 
of the person whom he visits ? If he derive anything specific from 
the sick, his disease is then, assuredly, not to be considered as oc- 
casioned by the atmosphere, but depending on the peculiar condi- 
tion of the fluids, or state of the system induced by the action of a 
specific poison ; in other words, it is to be considered a contagious 
disease." If then, we are to understand by a contagious disease, 
one capable of being transmitted by contact, nearly all of those 



104 ETIOLOGY. 

are so at times which have heretofore been spoken of as properly 
infectious ; but if by that term is intended such an affection as is 
ordinarily communicated by contact, it should be applied to those 
only which are inoculable, and not to such as arise under the in- 
fluence of local or general atmospheric conditions. When the 
question is proposed whether any particular disease is contagious, 
it must first be understood in which of the two senses just men- 
tioned the word is employed, and this being settled, an answer can 
be readily furnished by a reference to the history of the disease. 

The circumstances which render infectious diseases contagious, 
have been incidentally alluded to : they are, bad ventilation, want 
of cleanliness, crowding of the sick together, allowing their excre- 
tions to remain in the apartment, and, along with these, a calm and 
moist state of the atmosphere. Yet, there are probably some others, 
which have hitherto eluded detection. For example, typhoid fever, 
as it occurs in Paris, rarely, if ever, appears to be propagated by 
contagion, yet there is abundant evidence of the contagiousness of 
this very disease, in the country and villages of the French depart- 
ments. 

There is a feature characteristic both of infectious and conta- 
gious diseases, and which consists in what is called the period of 
incubation, a metaphorical term borrowed from the process by 
which birds hatch their eggs. Thus, a person who has passed the 
night in a malarious locality, may betray no symptoms of having 
contracted disease, until several days or weeks afterwards. A more 
familiar illustration of the phenomenon in question, is afforded by 
inoculable diseases. The virus of small-pox, vaccine, syphilis, or 
rabies, is introduced into the system, and yet several days, and in 
the case of rabies, several months may elapse without the slightest 
indication of the disease which is subsequently to appear. How 
the virus acts during this interval of apparent quiescence, and how it 
finally determines the reaction of the constitution, is altogether un- 
known. Liebig imagines this matter to consist of a sort of fer- 
ment, which, like the minute quantity of yeast that leavens a large 
lump of dough, gradually modifies the chemical relations of the 
fluid elements of the body. Other observers, upon the ground of 
an alleged discovery, that leaven acts by propagating vegetable 



MEDICAL CONSTITUTION. 105 

germs, suppose the different sorts of virus to contain animal ova, or 
vegetable germs, which, by rapid generation, fill the body with pa- 
rasitic insects or invisible plants, whose presence constitutes the 
disease. When the microscope shall have revealed the existence 
of either of these sorts of bodies, in the fluids through which ino- 
culable diseases propagate their kind, it will be time enough to give 
the hypotheses in question a serious consideration. Meanwhile, 
physicians may find abundant and more profitable occupation in 
investigating the relations of phenomena cognizable by the senses • 
in any other mode of searching for truth in our present subject, 
the most acute understanding is employed to little purpose. 

Medical Constitution. — The preceding remarks form a neces- 
sary introduction to a general notice of several remarkable modes 
in which infectious and contagious causes operate, or the circum- 
stances under which they act upon a large number of persons. 
The first of these we shall mention, is the medical epidemic con- 
stitution. This state has been erroneously defined the appreciable ag- 
gregate of meteorological conditions, during which diseases prevail 
epidemically. The phrase is synonymous with prevailing medical 
diathesis ; it relates entirely to the peculiarities of the prevalent 
diseases, and incidentally alone, and that by way of explanation, 
to the existing state of the weather. It has been more correctly 
described as a general tendency, by virtue of which, nearly all dis- 
eases, at a particular time and place, no matter how different in 
seat and character, assume, to some extent, a common aspect. 
Thus, inflammations of the brain or bowels may both be compli- 
cated with bronchitis, which complication is then said to be the 
effect of the medical constitution. In like manner, when various 
diseases are attended with symptoms which indicate disorder of the 
liver, the medical constitution is said to be bilious, and we have 
bilious pneumonia, bilious pleurisy, bilious remittent fever, &c. 
So, too, the prevalent type of disease may be either inflammatory, 
adynamic, or ataxic ; and thus it happens that an affection which, 
at one period, has been found amenable to a particular treatment, 
will, at another time, require an opposite management. Inflamma- 
tions which last year may not only have borne, but seemed to re- 
quire for their cure the most profuse loss of blood, may in the pre- 



]06 JETIOLUGY. 

sent, or the following year, be aggravated by moderate depletion, 
or even receive benefit from stimulating remedies. In connexion 
with this point, it may also be stated, that the alternate triumph and 
failure of the same remedy or class of remedies, has been observed 
even without there being any common feature in the diseases for 
which they were prescribed, or any, it would be more correct to 
say, which observation could detect. 

The medical constitution must not be confounded with epidemic 
disease, for the former is evinced by a common symptom or symp- 
toms in numerous affections otherwise dissimilar to one another, the 
latter is a definite and peculiar malady. Yet during the prevalence 
of an epidemic, some one of its principal features is very apt to dis- 
tinguish nearly all of the sporadic disorders which arise at the same 
time; so diarrhoea was an ordinary complication of most diseases 
during the prevalence of the cholera. In such cases it is fair to 
infer that the infectious cause of the medical constitution acquires 
unusual energy, not only capable of giving an impress to diseases 
generally, but of originating an independent malady. 

Endemic and epidemic diseases. — These words are derived from 
the Greek words sv, Srjixog, in or among the people, and s^i, Sr^xog, 
upon the people, the former indicating a prevalent disease arising 
from some local cause, and the latter one produced by an atmo- 
spheric or other general agency, operating upon the inhabitants of 
an extensive region. The one term refers to the place of a disease, 
the latter to its extent. Hence it is usual to speak of an endemic 
malady becoming epidemic. The yellow fever is endemic in Ha- 
vana and Vera Cruz, i. e. is generated by causes existing in and 
about those places, yet when it prevails in either it is described as 
an epidemic. The same disease, as it frequently prevails in New 
Orleans, cannot be called endemic, because if we are to believe the 
highest testimony, it never appears in that city unless imported 
from abroad. 

Another point of difference between the two classes of disease, 
is that the one is to a great extent permanent, or recurs peri- 
odically, in the same form, because its causes operate steadily or 
with regular intermissions, while the advent of the other is irregu- 



ENDEMIC AND EPIDEMIC DISEASES. 107 

lar and uncertain, and cannot be foretold, any more than its proba- 
ble form, extent, course, duration, or mortality. 

Most of the diseases which have already been described as in- 
fectious, belong to the class of endemic maladies, more particularly 
those of malarious origin, such as the different forms of remittent 
and intermittent fevers. But there are others which have long ex- 
isted in particular districts or countries, the causes of which may 
therefore be presumed to be local, although for the most part un- 
known. Cretinism, which consists in a stunted or imperfect de- 
velopment of the body, with mental imbecility, has for centuries 
affected many of the inhabitants of the valleys in the south of 
France, Switzerland, and Austria. Goitre, or hypertrophy of the 
thyroid gland, prevails in the same situations. Plica, called Polo- 
nica, from its prevalence in Poland and the neighbouring countries, 
is a disgusting malady, in which the hair is matted together by 
a dark-coloured glutinous secretion, exhaling a nauseous smell. 
Frambcesia, or the yaws, is a disease endemic on the Guinea coast, 
and in the West Indies, and is also highly contagious. It consists 
of a fungous eruption over a large part of the body, resembling 
raspberries ; whence its name. Elephantiasis in the West Indies, 
pellagra in Lombardy, and beriberi in Ceylon and on the Malabar 
coast, may also be classed amongst the strictly endemic diseases. 
Ophthalmia in Egypt, colic in Devonshire and Poitou, cholera in- 
fantum in the United States, trismus nascentium in the intertropical 
regions of America, are in some sense endemic or peculiar to cer- 
tain countries or districts, but they can generally be traced to 
causes which are well known and tangible, in which respect they 
differ entirely from those before enumerated. 

Epidemics, we have said, which are not, mere extensions of en- 
demic disease, epidemics properly so called, are for the most part 
independent of local causes ; they occur at uncertain intervals, 
prevail for indefinite periods, and in general attack the inhabitants 
of different regions, however dissimilar in climate and in the cha- 
racter of the people, and whatever the season of the year. The 
most remarkable amongst them for the wide extent of their ravages, 
are influenza and cholera ; the latter of which, starting from its 
lair in Bengal in 1817, has since that time made the circuit of the 



108 JDTIOLOGY. 

entire globe, seizing its prey in every climate and season alike. 
Epidemics, which, like this disease, the plague, and typhus fever, 
sometimes prevail extensively, and occasion a very great mortality, 
are usually denominated pestilential. As before remarked, there 
appears to be no uniform relation between them and the state of 
the weather, and this is true, though not literally, in the case of 
epidemics of more limited extent. Some have asserted that great 
commotions in the elements, earthquakes, hurricanes, volcanic 
eruptions, &c, give rise to epidemic disorders, but the assertion is 
unsupported by adequate testimony, and it is undeniable that these 
disturbances frequently occur without being followed by any such 
result. 

There is a combination of causes which has repeatedly been ob- 
served to occasion epidemics of typhus fever and dysentery, and 
which was alluded to in the remarks upon predisposing causes; it 
is that of famine amongst a people labouring under mental depres- 
sion and poverty, a combination which has lately worked such 
fatal mischief in Ireland, and even affected this country, by pour- 
ing upon its shores large numbers of persons labouring under the 
typhus fever, engendered by the causes in question. A scarcity 
of wholesome food imposes the necessity of consuming what is un- 
nutritious or positively injurious, and in this way both impairs the 
power of resisting disease, and occasions the development of dis- 
tinct disorders. Fodere, quoted by Dr. Copland, states that during 
1815, 1816 and 1817, in several parts of Italy and France, the 
inhabitants were obliged to have recourse to such roots and herbs 
as they could procure, the grain having been remarkably scarce 
and of bad quality, and that, in consequence, scurvy, diseases of 
the skin, and malignant and infectious fevers, became very preva- 
lent among the lower classes. It has occasionally happened that 
ergot, mixed with grain, has produced gangrene, abortion, &c, 
amongst the inhabitants of a considerable district. But this is a 
case of general poisoning rather than of an epidemic disease. Of 
a similar character are those instances of prevalent disease from 
eating the meat of animals which have been over-driven or in any 
way rendered unhealthy. Malignant typhus and dysenteric affec- 
tions are the usual effects of this cause. 



EPIDEMICS. 109 

Not only do general causes productive of debility favour the de- 
velopment of epidemic maladies, but weakness, in whatever man- 
ner occasioned, is the most evident cause of individuals being 
attacked by the reigning disorder. The disproportionate mortality 
amongst the drunkards of this country in the cholera of 1832, 
must still be fresh in the recollection of every one who witnessed 
the ravages of that disease; and European writers record a similar 
observation. During the prevalent influenza of 1837-38, the old 
and feeble were amongst the first victims of the complaint, and 
suffered more than younger persons throughout its entire course. 
It is a fact, established by universal observation, that none contract 
epidemic diseases more readily than those who live in constant 
dread of their attack. These circumstances, it will be remem- 
bered, were pointed out in the discussion of predisposing causes, 
but their influence is more perceptible in the case of epidemic 
than of sporadic diseases, because in the former the morbid cause 
appears to be endowed with greater energy. 

There is a feature, common to many epidemics, which must not 
pass without notice ; it is the faculty which they have of taking 
the place, either in whole or in part, of the sporadic diseases which 
ordinarily occur in the regions where they prevail. It seems as 
if all morbid predispositions were, on such occasions, forced to 
assume the same mode of active development by the superior 
power of the epidemic influence. In a previous section the fact 
was mentioned, that if a number of persons were exposed to cold 
and humidity, many among them would be affected differently, 
according to the organ most predisposed to disease in each ; con- 
versely, in the case before us, it would appear that in the infected 
district nearly every one must have his constitution modified in the 
same way by the morbid epidemic principle, since the same form 
of disease results, whatever be the character of the exciting cause 
which directly produces it. It is on this account that, in estimating 
the mortality of a place during an epidemic, the number of deaths 
arising from ordinary causes, during a corresponding season in 
other years, are not to be added to those produced by the epidemic; 
for it not unfrequently happens that although it may have destroyed 
a large number of individuals, yet the total mortality from all causes 

10 



110 .ETIOLOGY. 

may very little exceed the average of other years, so completely 
has the prevalent disorder become a substitute for the rest. We 
are accustomed to lament the insecurity of life in certain cities 
which are annually or periodically visited by epidemics, and to 
suppose their average mortality greatly to exceed that of places 
which enjoy an immunity from this evil ; but it results from the 
vital statistics of these cities that their total mortality is not greater 
than that of others, and that if they suffer more from epidemic dis- 
orders, fewer of their inhabitants die of sporadic disease. 

Endemic and epidemic diseases are propagated in one or both 
of two ways, by infection and contagion ; that is to say, imme- 
diately, by an atmospheric or other analogous cause, and directly 
or indirectly from the bodies of those who received the disease 
from that cause. It hence becomes a question of great delicacy 
and difficulty to determine how far a particular epidemic is conta- 
gious. The very fact that a large number of persons are attacked, 
argues a predisposition on their part, and it would therefore appear 
impossible to decide whether they contracted the malady from its 
original source, or from some of the persons around them already 
attacked. It is not a sufficient objection to the latter supposition, 
that they have had no communication with the sick, for the media 
of contagion are innumerable, and no one can tell with certainty 
whether he has been exposed to their action or not. On the other 
hand, it is not conclusive evidence of contagion, that a person going 
into a sick family has there acquired the disease, or that the mem- 
bers of that family have successively been attacked by it ; for it is 
highly probable that when several persons live together, and are 
subjected in all respects to the same local and general influences, 
they will all become liable about the same time to suffer from the 
same infectious cause. 

It may be supposed that where a disease is essentially conta- 
gious, and is communicable by inoculation, there can be no doubt 
of its being propagated, during an epidemic, by contagion alone. 
But this is far from certain. If a large number being attacked 
argues a strong predisposition on their part to the disease, who 
shall decide that this predisposition is not strong enough to engen- 
der the malady directly, and without the intervention of contact or 



CONTAGION IN EPIDEMICS. Ill 

communication with the sick ? It amounts to a strong probability 
that in certain epidemics, even of small-pox, the first cases have 
arisen spontaneously, because the subjects of them resided at con- 
siderable distances from one another, and had no intercourse, either 
direct or indirect. 

We are not entitled to conclude that a disease whose ordinary 
mode of propagation is by contagion, can be engendered in no other 
way ; it is evident that at some time or other contagious diseases 
must have sprung from a concurrence of natural causes, for there 
certainly was a period when they did not exist. If such causes 
were once adequate to their production, it cannot be denied that 
they may be so still, and that hence it is impossible to affirm, pre- 
cisely, what part is borne by infection and what by contagion in 
the spread of epidemics. 

The difficulties of deciding upon the contagious character of an 
epidemic, or the degree to which the disease possesses this charac- 
ter, are very much enhanced by the imperfect method of observa- 
tion which has generally been pursued in investigating this subject. 
It is apt to be forgotten that the condition of the sick person and 
of him who is exposed to contamination, as well as the virulence 
of the contagious principle itself, may all vary so much, as to mo- 
dify or reverse the ordinary liability of the disease to be dissemi- 
nated. The particular period of the disorder, the idiosyncrasies 
of those affected, and the parts or textures through which commu- 
nication takes place ; the actual health of the person exposed to the 
contagion, including his constitutional susceptibility, his strength 
or weakness, the state of his mind, and the duration of his expo- 
sure ; the state of the atmosphere as regards dryness, moisture, 
calmness, and renewal in the apartment of the sick; the nature of 
the substance, articles of clothing, &c, (fomites) which are sup- 
posed to have been the media of transmitting the contagion ; these 
points, which ought plainly to be ascertained in every case of pre- 
sumed contagion, are seldom investigated as they deserve to be. 
Dr. Holland, who insists strongly on their importance, remarks, 
" So far from being difficult to explain why a given disorder should 
occasionally appear infectious, (contagious) at other times not ; 
why it should spread rapidly in some localities, and not at all in 



112 .ETIOLOGY. 

others; why it should affect some persons and leave others free; 
why the cases should be violent at one period, mild in another, — 
it is rather perhaps matter of wonder that the circumstances are 
not still more varied and irregular. Where there are such numer- 
ous elements of difference, the combination of these may well give 
scope to every assignable variety of result." 

Abandoning, then, the attempt to determine by an infallible rule 
what cases of an epidemic disease are dependent upon infection and 
what upon contagion, we shall conclude this subject by pointing 
out the general grounds upon which the contagiousness or non- 
contagiousness of an affection ought to be decided, due regard being 
had at the same time to the modifying circumstances alluded to in 
the last paragraph. 

The question is, simply, do persons, ill of a given disease, com- 
municate it to others? Here it is necessary, at the outset of the 
inquiry, that there should be no other cause to which the sickness 
of the persons consecutively attacked can fairly be attributed ; the 
affection must not be an endemic one, habitually prevalent, or 
arising periodically, where the cases of it under examination are 
observed, nor traceable to any known atmospheric or other exciting 
cause, — it must be contracted by the previously healthy upon the 
arrival of one or more sick persons amongst them, in order that 
its contagiousness may be rigorously proved. 

When travellers affected with small-pox came amongst a tribe 
of our Western Indians, and one after another of its members was 
attacked by the disease, and nearly the entire tribe thus miserably 
perished, the proof that the malady was contagious became com- 
plete. But this highest degree of evidence can rarely be obtained, 
especially in large cities, where individuals may be attacked simul- 
taneously, who believe that they have not held any intercourse 
with those previously sick, but who may in reality have contracted 
the disease from them through indirect channels. Under such cir- 
cumstances the proof of contagion consists in the more frequent oc- 
currence of the disease amongst the nurses, attendants, families, 
and friends of the sick, than elsewhere, and it may be added, 
amongst the patients of the physicians who have charge of the 
greatest number of those suffering from the malady in question. 



PROOF OF CONTAGION. 113 

It is this latter evidence that places the contagiousness of puerperal 
fever (typhoid metro-peritonitis) beyond all cavil or reasonable 
denial. 

Other things being equal, the extension of the malady should be 
directly proportioned to the degree of communication with the sick ; 
those who are much in their apartments are more liable to suffer 
than casual visiters. And yet there is some limit to this proposi- 
tion, for it has sometimes been noticed that nurses and other con- 
stant attendants have escaped, altogether, or with slight attacks, 
when persons occasionally present have been more severely ill. 
It is supposed that the class of persons who appear to enjoy this 
partial exemption, become, as it were, acclimated by habitual resi- 
dence in sick rooms. Such may be the case, but their immunity is 
doubtless, owing, in some measure, to their having no fear of the 
danger. This sense of security, it may be conjectured, is the great 
safeguard of the physician in his perilous treatment of contagious 
diseases. Further; the contagious qualities of a disease are to be 
inferred from its extension to those who have been in contact with 
garments or any other articles impregnated with the atmosphere 
of the sick room. If the laundress who washes the clothes of the 
patient be attacked, no other cause of her illness appearing, it is 
reasonable to suppose the garments to have been the medium of 
contagion. 

The converse of the foregoing circumstances confirms by nega- 
tive, what they establish by positive proof. Thus if it be observed 
that no persons but such as hold communication direct, or indirect, 
with the sick, are attacked ; that just in proportion as the inter- 
course is restricted between the immediate locality of the disease 
and the adjacent districts, the progress of the disease is stayed ; 
that the removal of the sick to a distance, is followed by a cessa- 
tion of the malady, &c. — then upon these grounds alone there is a 
fair presumption that the disorder is contagious ; and, if in addition, 
the aforementioned direct evidence can be obtained, then no candid 
mind should entertain a doubt of the contagious nature of the 
disease. 



10' 



PART II. 

GENERAL PHENOMENA, THEORY AND CLASSIFICATION 
OF DISEASES.— GENERAL DIAGNOSIS AND PROGNOSIS. 



CHAPTER I. 

THE TYPE, DURATION, STAGES, AND TERMINATIONS 
OF DISEASE. 

By the course of disease is meant the mode in which its symp- 
toms arise and succeed each other. As their origin, succession, 
association, duration and tendency vary exceedingly, and yet ap- 
pear to be subordinated to general laws, in such wise that a know- 
ledge of these circumstances leads directly to the distinction of dis- 
eases from one another, and to some anticipation of their result in 
individual cases, it will be necessary to examine these several par- 
ticulars somewhat in detail. 

SECTION I. 

OF THE TYPE OR FORM OF DISEASE. 

Type, or general character of disease, is a term used to express 
the succession of symptoms in one of three ways, to which obser- 
vation teaches that all diseases more or less strictly conform. The 
first of these is the continued type, or that of diseases which go on 
from beginning to end, without material interruption or abatement. 
But these affections can be called continued in a comparative sense 
alone. None of them maintain strictly the same uniform intensity 



TYPE OF DISEASE. 115 

throughout their course, but on the other hand, they offer none of 
those decided interruptions of activity which belong to the other 
types. No disease is equally severe at every period of its pro- 
gress ; it must run through certain stages, which alone would pre- 
vent its being literally continued, and, moreover, none is exempt 
from occasional augmentations of severity, which are called exacer- 
bations, and which, at times, occur with such regularity every 
morning or evening, or on every other day, as to place the disease 
amongst those of the remittent or intermittent type. Of this, the 
fever called remittent affords a striking illustration. In the early 
part of its course, it runs steadily on with little or no deviation from 
a certain intensity ; subsequently it becomes marked by periodical 
exacerbations, and not unfrequently, at a later period, distinct 
paroxysms occur, separated by complete intermissions. This, and 
many analogous facts, have led to an opinion extensively enter- 
tained, that periodicity is the natural or primordial type of diseases 
attended with reaction. The type is intermittent when a disease 
is composed of separate paroxysms, in the intervals between which, 
the patient is free from any symptoms indicative of the disease 
under which he labours. A disease of this type is said to be regu- 
larly intermittent, when the paroxysms return after equal spaces of 
time, whether these be measured by hours or days. In febrile dis- 
orders, the interval between the paroxysms is termed apyrexia, (a 
priv., and tfup, fever), in other intermittent affections, the convul- 
sive, for example, the occurrence of the morbid phenomena is called 
a Jit. There are several varieties of the intermittent type : the 
quotidian, in which the paroxysm occurs daily; the tertian, in 
which it occurs every third ; the quartan, in which it occurs every 
fourth day, &c. These are elementary types, and may be va- 
riously combined. Thus, either may be doubled, so that two pa- 
roxysms fall on the same day, or two distinct series of paroxysms 
may exist, occurring on different days, but separated by the usual 
intervals. Regular intermittence is of extremely rare occurrence 
in any other disease than intermittent fever ; next to which, neu- 
ralgia most frequently assumes this character. The periodicity 
which is observed in hectic fever, does not belong to the type under 



116 COURSE OF DISEASE. 

discussion, because depending upon profound, and generally incu- 
rable organic disease. It is characteristic of true intermittence, 
that its cause is occult, and has never been even plausibly assigned. 
In some cases of convulsive disorders which are marked by irregu- 
lar intermissions, it is, indeed, often impossible to specify the cause 
of a particular attack, yet this can most generally be done ,• but 
just as they approach to regular periodicity, the cause becomes ob- 
scure, and even eludes pursuit entirely. The remittent partakes of 
the characters of both the other types of disease. Its most striking 
illustration is the malarious disorder known as remittent fever, 
which presents, in common with intermittent fevers, paroxysms 
marked by chill, fever, and sweat, and in common with continued 
fever, excitement of the circulation, and various disorders of inner- 
vation and secretion, which persist with more or less violence 
throughout the disease. 

SECTION II. 

OF THE DURATION OF DISEASES. 

The period intervening between the invasion and the termination 
of disease, may vary in length from a few minutes to the greater 
portion of a lifetime ; but experience teaches that nearly all dis- 
eases may be divided into two classes, viz., those which tend to ter- 
minate within a comparatively short time, and those whose dura- 
tion is uncertain and indefinite. The former are termed acute, 
(acutus, sharp, brought to a point, viz. of time,) not only, perhaps, 
to express the shortness of their course, but also their sharpness or 
severity, since their general character, as compared with chronic 
diseases, is violence, a quality which in many of them is propor- 
tioned to their brevity. Instances of this fact are found in apo- 
plexy, and some other hemorrhages, in cholera, and in peritonitis 
from perforation of the intestine ; but the rule is not absolute, for 
several of the mildest disorders have the briefest existence, and on 
this account are called ephemeral. Such are most of the slight in- 
flammations of the mucous membrane. It is, of course, impossible 



DURATION OF DISEASES. 117 

to fix a term within which all diseases shall be considered acute, 
but by general consent, those are so regarded which do not extend 
beyond forty days ; or, more precisely, the name is restricted to 
such as are not prolonged beyond about half the period named, and 
that of sub-acute conferred upon those which attain the further 
limit. Considering the number, the frequency, and the severity of 
acute diseases, it is remarkable that, in their sporadic form, they 
should be so seldom fatal. They very commonly evince a natural 
tendency to cure, which contrasts strongly with the more general 
direction of chronic maladies to a fatal termination. 

There is a class of acute diseases, whose duration is so nearly 
uniform, that it may be called definite. These are the exanthemata ; 
in the large majority of cases, each one of their stages occupies a 
given number of days, so that the duration of the disease itself may 
be pretty safely predicted. The patient, however, may be more or 
less enfeebled, according to the severity of the attack and its com- 
plications. His recovery, therefore, does not always date from the 
cessation of the primary disease. 

Chronic diseases (^povos, time), are those which are of slow 
progress, and exceed in duration the ordinary existence of the acute 
class. They may arise as consequences of acute disorders, or be 
developed originally in the form which they long afterwards pre- 
serve. For the most part, their symptoms are not violent, and if 
they cause pain, it is only at considerable intervals of time, or when 
they are approaching the fatal conclusion to which most of their 
number tend. They are, in a majority of instances, connected 
with some organic lesion, a fact which explains their ordinary re- 
sult, as well as the general loss of health which the subjects of 
them experience. These affections are very apt to be complicated 
with acute diseases, either from the progress of the lesions which 
are peculiar to them, or from weakening the constitution, and thus 
predisposing it to suffer from external morbid influences. 



118 COURSE OF DISEASE. 



SECTION III. 



OF THE STAGES OF DISEASE. 



Pathologists usually divide the course of disease into three pe- 
riods or stages : the first, that of increase ; the second, that of 
acme, in which the symptoms remain stationary; and the third, that 
of decline. But these stages are far from existing in all diseases, 
or of following one another in regular succession. In acute dis- 
eases alone, are they presented with distinctness and regularity. 
There are some affections which may break out suddenly, in their 
full force, so that the first stage is wanting, and others which 
terminate abruptly in death, without any period of decline. 

In others, again, there may be more than one acme; in small-pox, 
for instance, active fever precedes the eruption, abates upon its ap- 
pearance, and is again lighted up during the maturation of the pus- 
tules. Notwithstanding these numerous exceptions, some one stage, 
at least, is marked in every disease; that of invasion, more frequent- 
ly, perhaps, than the others. This one is highly important in its re- 
lations to diagnosis and treatment. In acute diseases, the invasion 
is usually attended by a chill, followed by fever, nausea, vomiting, 
pain, and loss of strength ; in children, convulsions are often the 
initial symptom ; in females, syncope ; and in many persons, 
symptoms peculiar to the disease about to be developed. Such are 
pain in some particular organ threatened with inflammation ; pain 
in the loins preceding eruptive fevers ; epistaxis before typhoid 
fever, &c. As the disease advances, the functions grow daily 
more and more disordered ; the physiognomy more altered ; the 
thirst more urgent, digestion feebler, the tongue fouler, the pulse 
more frequent, and the skin hotter. These changes are completed 
in the course of a few, rarely more than seven, days, and retain 
their severity, or experience a somewhat further aggravation, dur- 
ing another period, and until the stage of decline arrives. The 
transition from the first to the second stage, of growth to maturity, 
and even, (though not so constantly,) from the latter to decline, is 



STAGES. 119 

so gradual and often imperceptible, that it is not possible to say 
when the one ceases and the other begins. 

During the stage of decline, the symptoms begin to subside, the 
general symptoms first, and then those belonging more immediately 
to the local lesion, if any there be. It is of importance, in practice, 
that temporary remissions be not mistaken for the permanent im- 
provement which precedes convalescence, — that the practitioner 
should not allow himself to be deceived, nor induced by apparent 
amelioration to flatter the patient and his friends with false hopes. 
Due regard must be paid to the period at which the improvement 
takes place, and to its maintaining itself for a reasonable time, be- 
fore it can be considered as belonging to the regular decline of the 
disease. Convalescence is described by some writers as included 
in this stage, and although oftentimes, doubtless, the one passes 
into the other by insensible gradations, it seems more appropriate 
to regard convalescence as one of the terminations of disease, under 
which head it will be duly considered. 

The stages of chronic maladies are generally less distinctly 
marked than those of the acute; they are always of longer dura- 
tion, and more liable to accidental modifications. The formative 
period is, for the most part, obscure, and may extend through 
many years ; it sometimes, however, presents decided symptoms, 
which clearly indicate the future disease. Thus, in pulmonary 
consumption, it is not unusual for haemoptysis, or a mere loss of 
flesh without assignable cause, to precede by many months the 
proper symptoms of the malady ; a similar remark is applicable to 
several of the forms of cancer, and to most of the organic diseases 
of the heart. In most of such examples the second stage consists 
merely of an aggravation of the symptoms observed in the first, 
together with a more distinct and characteristic display of local 
symptoms. The decline of these affections, when they tend to a 
fatal issue, is marked by the most striking symptoms both local 
and general; the former vary with each particular malady, but 
several of the latter are common to nearly all internal chronic dis- 
eases ; such are progressive emaciation, colliquative diarrhoea and 
sweats, and that breaking up of the constitution which is attended 
by hectic fever. 






120 COURSE OF DISEASE. 

The characters of disease which have now been described are 
modified by various circumstances, which should be known, lest a 
too absolute idea be entertained of the regularity with which morbid 
phenomena are developed. Diurnal changes appear to have a de- 
cided influence on the course of disease. Before daybreak sweats 
are frequently observed, both in acute and chronic disorders ; this 
is the period in the twenty-four hours when the system seems 
most to require support, when absorption is most active, (as shown 
by the disappearance or abatement of oedema of the extremities,) 
and when, according to some authorities, medicines intended to act 
through this medium are most efficacious. It is also alleged that 
soon after sunrise the signs of plethora are more distinct than at any 
other time, and that in affections attended by fever, there is usually 
a slight exacerbation about noon. These statements may admit 
of some question ; but there can be no doubt that the symptoms of 
nearly all diseases are aggravated at the close of the day, and 
usually continue to grow worse until after midnight. The sick, 
wearied with the noise, and movement and light of the day, be- 
come exhausted, and at the same time restless and uneasy ; as 
night advances the fever increases, and with it the disturbance of 
the mind, which, in severe cases, attended by sleeplessness, is apt 
to pass into delirium. Some chronic diseases display their severity 
almost exclusively by night; such are rheumatism, especially of 
the syphilitic form ; asthma, whether nervous or dependent upon 
emphysema of the lungs ; aneurism of the great vessels, diseases 
of the heart, large tumours of the abdomen, and dropsical effusions 
which impede respiration in the recumbent posture, &c. 

Temporary changes in the weather do not exert a very marked 
influence on the course of disease, except when very sudden and 
extreme, and chiefly when they consist of a rapid transition from 
heat to cold. Chomel remarks of hospital patients, that when cold 
weather abruptly succeeds a moderate temperature, most of those 
who are in a very low condition die within twenty-four or thirty- 
six hours, a circumstance peculiarly noticeable in institutions which 
receive the aged only. Neuralgia and rheumatism are generally 
aggravated by cold weather, particularly if it be also damp. 

Spring and autumn, the seasons in which the greatest vicissi- 



INFLUENCE OF THE WEATHER, ETC. 121 

tudes of temperature occur, are also those most prejudicial to chro- 
nic complaints. In Europe there is a popular notion that the sick 
are very apt to die when the leaves fall, and external nature tends 
to decay ; a similar idea is entertained here in regard to the bois- 
terous month of March. Many consumptives look forward to its 
approach as the sure termination of their lives. During the entire 
cold season chronic maladies are aggravated, and those not imme- 
diately fatal are infinitely more intractable than at any other time. 
So powerful is this influence that the same remedies which have 
been fruitlessly employed during the winter, seem to acquire new 
power on the approach of spring, in consequence of the disease 
then assuming a mitigated form. Mr„ Phillips has copiously illus- 
trated this fact in his work on scrofula. 

Lunar influence was formerly believed to control the ebb and 
flow of disease as certainly as it does the tides. The arguments 
in favour of this doctrine were chiefly drawn from the phenomena 
of nervous diseases ; but it has gone nearly out of favour, and the 
only remnant of it remaining is an opinion that the insane are pe- 
culiarly liable to exacerbations of their disorder at the full moon. 
Indeed, a residence in an insane hospital must convince any one 
that about this period maniacal patients, and all disposed to be 
noisy, are more obstreperous than usual, and that, especially, by 
night. But it has been conclusively shown by Esquirol and nume- 
rous other observers, that the moon produces these effects through 
the influence only of her light, which, as every one knows, pre- 
vents or disturbs the sleep of many who are also rendered wakeful 
by the extravagant fancies of a disordered brain. 

Food and drink, labour and rest, pain and pleasure, mental ex- 
citement or depression, and many other analogous circumstances 
which it would be impossible even to enumerate, have a very de- 
cided influence upon the character and issue of diseases. Chomel 
and Dr. Latham dwell upon the power of fatigue in aggravating 
diseases of the heart, and every physician who has passed much 
of his time in hospitals will confirm their remarks. Frequently, 
some of the greatest symptoms of these maladies, such as dyspnoea, 
and cedema of the lower limbs, disappear after a few days' rest. 
The subjects of these cases nearly always belong to the most indi- 

11 



122 COURSE OF DISEASE. 

gent and laborious classes of society, in whom scanty and bad food, 
intemperance, and exhausting labour, produce symptoms which the 
cardiac disease would not of itself have induced until a much later 
period. Nearly every disease, in persons of this class, is singu- 
larly improved by the comforts and repose of a public institution. 
Consumption, dysentery, rheumatism, and insanity may be men- 
tioned as peculiarly apt to improve from this cause. 

The age of the patient plays an important part in regulating the 
duration of his disease. The diseases of infancy and childhood 
are, with few exceptions, short and active; those of old age, on the 
contrary, are more apt to be subacute and chronic. In the early 
periods of life the severest symptoms are often followed by sudden 
and unlooked-for recovery ; " childhood is the age of resurrec- 
tions :" in advanced life, the slightest attack of disease requires 
watching, for it is often the prelude to a fatal seizure. The dis- 
eases of males have, for the most part, bolder features, and a more 
regular course than those of females, in whom the nervous tem- 
perament and disorders of the uterine system give rise to the most 
whimsical irregularities and the most unmanageable complications. 
Pregnancy is reputed to exert a strong control over many dis- 
eases, and even to have effected a cure in rheumatism, hysteria, 
insanity, cutaneous affections, &c, and what is still more surpris- 
ing, to have suspended the progress of organic diseases. It is 
alleged that consumptive females often have the development of 
pulmonary tubercles arrested until after parturition, when the dis- 
ease resumes its downward course. If phthisis always ran its 
course in a given time, the influence of pregnancy in retarding it 
could easily be determined ; but since nothing is more variable 
than the duration of tubercular disease, it becomes a most difficult 
problem to solve, whether or not the cause assigned for the exten- 
sion of the cases in question was the real one. It is also a fact, 
which cannot be gainsaid, that pulmonary consumption does 
sometimes arise, and run on towards its fatal termination, precisely 
as in the unimpregnated state of the female ; but whether it does 
so or not in the greater number of cases, is still undetermined by 
adequate evidence. 



TERMINATIONS OF DIS E A S E. 123 

SECTION IV. 

OF THE TERMINATIONS OF DISEASE. 

All diseases end ultimately in recovery or death, but they do 
not always reach either point without passing through one or more 
of several intermediate gradations, which, relatively to the original 
disease, may be called terminations. These we shall discuss suc- 
cessively, giving, 1st, some account of recovery in general ; 2d, of 
convalescence; 3d, of crises and critical days; 4th, of metastases; 
and 5th, of death, and its several modes or varieties. 

Recovery is said to have taken place when the functional or 
organic derangement in which the disease consisted has entirely 
ceased, and the system has returned to its wonted condition. The 
mode in which this occurs is extremely diversified, for it varies 
with the organ affected, and the nature, degree, &c, of the affec- 
tion. As already intimated, the constitutional symptoms are the 
first to disappear, pain, and the other morbid phenomena belong- 
ing to the nervous system, usually taking the lead ; then the dis- 
turbance of the circulation ceases, the general operations of the 
economy resume their natural course, and, last of all, the injured 
organ regains its proper function. When the disease consists of 
constitutional disturbance alone, as in idiopathic fevers, the circu- 
lation gives, in general, the earliest evidence of improvement, the 
pulse approaching more nearly to the standard of health; then 
follows the amelioration of the nervous symptoms, including an 
increase of strength, and ultimately the secretions and excretions 
become natural. Paroxysmal disorders mark their subsidence by 
a gradual diminution in the violence of the attacks, unless, as fre- 
quently happens in intermittent fever, they are cut short by the 
treatment employed. 

In local diseases, so called, in those, namely, where the system 
sympathizes but feebly with the lesion of texture, and in those also 
where such sympathy is strongly marked, but. is strictly propor- 
tioned to the degree of the local alteration, the termination may 
occur in either one of several ways. The most favourable is that 



124 TERMINATIONS OF DISEASE. 

by resolution, in which the entire result of the morbid process is 
removed, and the part is restored to its pristine integrity. In 
literal terms this seldom occurs, except upon a cutaneous or mu- 
cous surface. There are few diseases of a parenchymatous organ, 
or of a serous structure, that do not leave some trace behind, though 
it is often so inconsiderable as in no wise to interfere with the func- 
tion of the part. Sometimes an alteration disappears suddenly, as 
in cutaneous affections the eruption may abruptly recede. This, 
in the case mentioned, is termed repercussion. The French patho- 
logists give the name of delitescence to every sudden removal of the 
results of morbid processes. Numerous diseases, which consist 
almost entirely of a single symptom, are sometimes abruptly 
arrested in their course, as neuralgia, hemorrhage, and the mu- 
cous fluxes. Suppuration, gangrene, and cicatrization, are also 
terminations of the local elements of disease ; but as they, with 
those just enumerated, are all peculiar results of inflammation, 
their further discussion may be for the present postponed. 

The immediate consequences of the processes just described is 
not absolute health, but a state which is introductory to it, an in- 
termediate condition, in which the patient cannot be said to be 
either sick or well, but in which he is convalescent, (from conva- 
lesco, I increase in strength) ; he is cured, but is still feeble, and 
has not yet completely recovered his vigour. Although the term 
convalescence is not used in connexion with the local process of 
cure, yet the part affected passes through a corresponding state. 
A wound, although cicatrized, is for some time prone to open from 
slight injuries; a fractured limb, although perfectly consolidated, 
continues weak, perhaps for months, &c. ; indeed, the convales- 
cence of the entire system is nothing more than the aggregate of 
the improved conditions of all the parts which have been impaired 
by disease. 

In chronic disorders convalescence is singularly slow. It is long 
before the patient can get rid of the expression which suffering has 
impressed upon his features; for a long time his gait is tottering, 
for his shrunken limbs are slow in regaining their former size, 
and that partly because his appetite is feeble, and his digestion 
slow. The older he is the more tedious and uncertain is his pro- 



CONVALESCENCE. 125 

gress towards health. Young persons recover more rapidly. I 
have seen a lad convalescent from coxalgia who was carried on 
pillows to the sea-shore, pale and extenuated, in a few weeks after- 
wards capering in high glee amongst his playmates, as fat and 
sunburnt as the rest. 

Recovery from acute diseases is more rapid, and marked by 
more peculiarities. The first signs of the decline of the disease 
after the cessation of fever, are emaciation and paleness. In most 
febrile diseases the body appears swollen so long as the heat of skin 
persists, but no sooner does the circulation fall to its natural stand- 
ard, and the surface grow cool, than the flesh seems to shrink. 
At the same time the patient begins to be conscious of his debility ; 
his limbs, his voice, his mind, are all feeble, and, though he enjoys 
the luxury of thinking without pain, yet the slightest argument, or 
contradiction, will ruffle his temper and bring on headache, rest- 
lessness, or fever. Even agreeable conversation, if prolonged, or 
pleasing intelligence if abruptly communicated, may produce the 
same effect. This susceptibility of the nervous system does not 
seem to be entirely removed by sleep, which is rarely sound, but 
commonly disturbed by dreams in which enticing scenes of feast- 
ing and other carnal pleasures mock the fancy. This is doubtless 
owing in a great measure to defect both in the quantity and quality 
of the blood ; the paleness of the tissues shows that this fluid is 
scanty and impoverished. This condition is further indicated by 
oedema of the face and lower limbs, and by shortness of breath and 
palpitations of the heart which come on after any unusual although 
slight exertion. On such an occasion, if the heart and large arte- 
ries are ausculted, a bellows murmur will be heard instead of the 
first sound of the heart, and a sound of similar character, or a 
humming or musical note will be audible in the vessels. 

Meanwhile the tongue begins to lose its morbid coating, and 
hunger becomes as imperious as was the longing for liquids during 
the height of the attack. At first, perhaps, food may seem "to lack 
its appropriate savour, but it soon affords so exquisite an enjoyment 
that the patient is very apt, in eating, to exceed the bounds of mo- 
deration, and overtask his stomach. Some years ago a patient in 
the Blockley hospital who was convalescent from typhoid fever, 

11* 



126 TERMINATIONS OF DISEASE. 

devoured his food so greedily, that a piece of tough meat contained 
in the soup he was eating, became wedged in his rima glottidis, 
and before assistance could be rendered, put an end to his life. 
The proper medium between abstinence and over indulgence of the 
appetite is not readily found at this period of imperfect restoration 
of the patient's health, and yet upon its due observance depends 
the rapidity of his recovery, and oftentimes the prevention of a re- 
lapse. In some diseases where the digestive organs have themselves 
been the seat of inflammation or other lesion of texture, the ma- 
nagement of the diet during convalescence is of infinite importance. 
The greater numbers of cases of perforation of the intestine after 
typhoid fever are due to the imprudent and premature ingestion of 
solid food. 

The bowels of convalescent patients are Usually torpid ; often 
the dejections are of a light colour, indicating the absence of bile ; 
the stomach is apt to become distended with gas after eating ; in a 
word the digestive function is not yet equal to the labour it is re- 
quired to perform, and until the whole system has become invigo- 
rated by exercise, the alvine discharges do not resume their natural 
appearance. At the period of which we are treating there is a 
remarkable sensibility to cold ; the hands and feet are habitually 
cool, and the least exposure excites a feeling of chilliness. The 
hygienic relations of this fact are of high importance. 

After fevers, and more especially the exanthemata, there is more 
or less desquamation of the skin, and a herpetic eruption appears 
upon the lips. Not unfrequently the hair falls out, and is very apt 
to reappear of a different shade and texture, or else it grows again 
but partially, leaving the crown of the head bald. It is not un 
common for the hair to become gray after a severe febrile attack 

There is a class of phenomena described by some writers as con 
secutive, and which are generally manifested during convalescence 
although, as they may extend far beyond this period, they cannot 
properly be said to belong to it. Such, for instance, is the jaun 
diced hue of the skin, which remains for a long time after the ob 
struction in the gall ducts, or whatever else may have caused it 
has been entirely removed. These phenomena are frequently at 
tributable to a partial continuance of the textural lesion peculiar to 



CKISES. 



127 



the disease ; to imperfect cicatrization of the brain in the case of 
prolonged feebleness or trembling of a limb after an attack of 
apoplexy; to thickening of the lining membrane of the larynx 
when the voice continues to be hoarse after croup or simple laryn- 
gitis ; to partial closure of the ulcers of the colon when the bowels 
remain irritable after dysentery, &c. In diseases which have no 
acknowledged anatomical lesion, in which function only is disor- 
dered, we are led by analogy to conjecture that the molecular 
alteration in the instrument of the deranged function has not en- 
tirely disappeared, when we find occasional indications of weakness 
in the performance of the function after the complete restoration 
of health in all other points. One of the most remarkable of the 
phenomena under notice is the recurrence after intermittent fevers, 
and on the days corresponding to the paroxysms, of slight chilli- 
ness, or flushes of heat, or pain, loss of appetite, or a copious late- 
ritious sediment in the urine. 

Crises. — The word crisis in the original Greek signifies a judg- 
ment, or judicial decision, because by it the life or death of the patient 
is determined. It is not every change of a disease, though it tend 
directly to a favourable or fatal termination, which is called a cri- 
sis, but only that which happens suddenly, and is preceded or at- 
tended by some remarkable disturbance of the body, and followed 
by a decided alteration of the symptoms either for better or worse. 
The phenomena which accompany the change are called critical, 
and the evacuation, if any, which at that time takes place, a criti- 
cal discharge. 

There is no point of medical doctrine which has been more gene- 
rally and more intemperately contested, than that which relates to 
the crises of disease, their causes, their effects, the days on which 
they occur, &c, and some have even gone so far as to deny their 
existence altogether. It is true, that this last sign of incredulity 
has been given only in very modern times, when to doubt, seems 
more proper to man than to believe. It has been advanced, in ex- 
planation of this denial of an opinion accredited in all previous 
ages, that the climates of northern Europe, where medical inqui- 
ries have, in recent times, been chiefly made, and of this country, 
where the unbelief is equally general, are very different from that 



128 TERMINATIONS OF DISEASE. 

of ancient Greece, where the doctrine first prevailed ; that modern 
physicians are more prone to disturb the salutary efforts of Nature 
than the ancient, or than those even of whom Galen complained, 
that they were never satisfied without they had administered a clys- 
ter, opened a vein, or applied cupping-glasses, and could not come 
near a patient without doing some mischief; that our system of 
dietetics for the sick is not as rigid as that of ihe ancients, &c. 

The learned and acute Van Swieten, however, who admits such 
reasons to be not without their weight, is still of opinion that the 
chief reason of our not observing crises, is because we neither know 
how, nor will take the pains to look for them. He relates, that 
having collected some hundreds of acute cases, not trusting to his 
memory, but tvriting down before the patient everything he could 
observe each day through the whole course of the disease, he with 
great pleasure saw that the results of his observations agreed sub- 
stantially with those of the ancients, and that " the chief fault lay 
in our being so forward to make the ancient physicians wiser, and 
presage more than they intended." He then proceeds to show 
that it was never pretended that crises happen in all diseases, nor 
that every disturbance and discharge are to be regarded as critical, 
nor that every crisis is necessarily followed by a decided and per- 
manent change in the disease, either for better or worse. It is 
freely admitted by the author just quoted, that critical changes may 
be delayed or suspended, or entirely prevented, either by the phy- 
sician's interference, or by that of persons, or causes, over which 
he has no control ; that yet, if they actually exist, they deserve to 
be attentively studied, for they teach us in what manner Nature 
cures diseases, and afford us a motive for not disturbing her in her 
salutary work by any impertinent endeavours to substitute for hers, 
inferior processes of our own invention. 

But on the other hand, that such forbearance would not necessa- 
rily result in showing critical phenomena to be of ordinary occur- 
rence, may be inferred from a statement made by Chomel, in re- 
gard to this point. " Tn a large proportion of acute disorders," he 
remarks, " and especially in inflammations of moderate severity, I 
do not, as a general rule, employ any of those active remedies 
which are held capable of preventing critical phenomena, and lam 



CRITICAL PHENOMENA. 129 

bound to declare, that in a vast majority of the cases, I Jiave seen 
the patients get well without any remarkable phenomenon to sig- 
nalize their recovery : a gentle perspiration, more copious or more 
loaded urine, a few evacuations by stool, cannot, in my opinion, be 
looked upon as critical phenomena. I hold them to be such, only 
when something unusual in their nature or degree, — something, in 
fact, which distinguishes them from the symptoms of ordinary dis- 
eases, arises to arrest attention." 

When, however, it is remembered that, when Chomel expressed 
this opinion, the principal sphere of his observation had been the 
wards of an hospital, there is less reason to be surprised at his be- 
lief in the infrequency of critical phenomena; for the remark of 
Dr. Conolly is a just one, that country practitioners, long engaged 
in watching maladies at the bedside, are more likely than hospital 
physicians, who make but a daily and formal visit, to witness the 
critical phenomena of disease. 

It is worthy of remark, too, that M. Grisolles, who collected the 
larger part of the materials for his classical work on pneumonia, in 
the wards of M. Chomel, as resident medical officer, and therefore 
in constant communication with his patients, states, that of one 
hundred and thirty cases of pneumonia proper for the inquiry, one 
fourth began to recover on the supervention of critical phenomena, 
and further, that the proportion of patients who manifested them, 
was greatest among those whose treatment was least active. Be- 
lieving, for our own part, that the weight of evidence is entirely in 
favour of their reality and importance, we shall proceed to lay be- 
fore the reader a summary of their most ordinary forms. 

Critical phenomena manifest themselves on the mucous mem- 
branes; on the skin ; in the glands; the cellular tissue; and the 
serous membranes. 

A critical discharge from the ?nucous membranes is usually in 
the form of a flux, and frequently indicates the cessation of inflam- 
mation in this tissue. A copious watery discharge from the nos- 
trils, often announces the sudden solution of a coryza, which had 
entirely impeded the passage of air through these openings ; dis- 
charges of a similar kind, or of mucus, from the bronchi, intestinal 
canal, or vagina, have immediately preceded the cessation of mala- 



130 TERMINATIONS OF DISEASE. 

dies not seated in either of these parts. I have seen the cure of an 
ovarian tumour large enough at last to fill the whole abdomen, 
take place upon a copious discharge of serous fluid from the vagina, 
which lasted for about a week. The patient had borne the disease 
for five years, and except that, towards the conclusion, its size and 
weight began seriously to incommode her, and that, at one time, 
she was greatly exhausted by injudicious evacuant treatment, her 
health had been excellent; her menstruation was regular; for a 
year, at least, previous to the event, she took no medicine ; nor 
could any cause whatever be discovered for the fortunate occur- 
rence which restored her to comfort at the very time when she was 
threatened with suffocation from the growth of the tumour. The 
cessation of ascites, upon the occurrence of repeated serous evacua- 
tions from the bowels or bladder, is an event of much more ordi- 
nary occurrence, and doubtless gave rise to the treatment of the 
disease by means of hydragogue cathartics and diuretic medicines. 
The secretion of saliva sometimes becomes very abundant, and has 
been regarded as a critical phenomenon in adynamic and intermit- 
tent fevers. 

Hemorrhage from mucous membranes has been regarded in the 
same light, and with better reason : from the rectum, it sometimes 
attends amelioration of the symptoms in several inflammatory dis- 
eases, and particularly in that of the liver; epistaxis has a similar 
value in inflammations of the chest and head, particularly when 
copious; bleeding from the lungs, stomach, or kidneys, must nearly 
always be regarded unfavourably, even when decidedly critical, 
unless the discharge appear to be a substitute for that of the cata- 
menia. 

Certain states of the urine were formerly regarded as indicating, 
more certainly than any other circumstance, the occurrence of 
crisis in disease, and to ascertain them, great care was taken in 
examining this fluid at each visit of the physician. At the height 
of the disease, if the urine became turbid upon standing, and depo- 
sited a lateritious sediment, the early subsidence of the symptoms 
was pretty confidently expected, and, unless this condition of the 
renal secretion were present, other apparently critical phenomena 
were held to be of little value. Since the revival of pathological 



CRITICAL PHENOMENA. 131 

chemistry, the urine has been the subject of minute study by a 
great number of physicians, and the value of the signs derived 
from it, as will be more fully shown hereafter, has been amply de- 
monstrated ; but so far as they relate to our present subject, the 
only new result obtained, is the fact observed by Martin-Solon, 
and others, that during the decline of many acute diseases a co- 
pious deposit of coagulated albumen takes place, when the urine is 
treated with nitric acid or heat. 

Critical siveating is alleged to be of frequent occurrence in acute 
diseases, and it occasionally puts an end to dropsical effusions ; 
but, as daily observation teaches, the occurrence of this excretion 
is by no means a uniform indication of the subsidence of a disease. 
The copious and exhausting sweats of rheumatism are familiar to 
every physician; such only, however, are to be considered critical 
as come on suddenly after the skin has been for some time hot and 
dry, and which are accompanied by an improved state of the pulse. 
Miliary eruptions, or sudamina, may be regarded as critical under 
like circumstances; they are of too ordinary occurrence during 
the height of typhoid fever, pneumonia, rheumatism, &c, to be 
looked upon at that period as anything more than a complication. 
Other cutaneous eruptions, of the pustular or squamous classes, 
are occasionally critical, and have been observed to attend the sus- 
pension of acute and chronic bronchitis, and, in some happy ex- 
amples, their appearance has proved the cure of insanity. Esquirol 
and Rayer both relate such cases. 

Besides the critical secretions from glands, noticed above, these 
organs sometimes indicate, by their swelling, the occurrence of a 
crisis. The parotid glands occasionally become swollen, and even 
suppurate, during the decline of typhoid fever; and inflammation 
of the lymphatic glands of the groin or axilla is said to be critical 
in the plague. Swelling of the testicle has been noticed as critical 
in catarrhal affections. 

The cellular tissue has been regarded as the seat of critical phe- 
nomena in such cases as the following : when it is distended with 
a serous effusion in certain acute diseases; when boils form within 
it, and sometimes, even, when it is attacked with carbuncle and 
gangrene. But these, like the so-called critical phenomena mani- 



132 TERMINATIONS OF DISEASE. 

fested by serous membranes, are complications which do not modify 
the existing state of the original disease ; they merely add to it 
conditions which increase the patient's danger. Effusion into the 
several serous sacs, although it may allay the violence of the in- 
flammation, forms part of the disease, and is not, like a crisis, 
something incidental and superadded. 

Critical phenomena, like all the other symptoms of disease, are 
subject to an infinite number of disturbing influences — to all, in 
fact, which in any way act upon the sick. They are more com- 
mon and more distinct in those of strong constitution, in infants 
and young persons generally, in temperate climates, in elevated 
situations, in the spring season, &c. ; whenever, in other words, 
there is but little to interfere with the regular course and develop- 
ment of the malady. Old and feeble persons, and those in unfa- 
vourable conditions as regards residence, climate, food, attendance, 
&c., are much less apt to have their diseases marked by crises ; 
and when this happens, it is usually by some mucous or serous 
discharge, while hemorrhages and sweats are more frequently met 
with in those of vigorous constitution. 

Critical Days. — The doctrine of critical days, which is, that 
crises occur on certain days rather than on any others, must be 
judged independently of that of crises themselves. The latter may 
be, and we believe is, true, because the most accomplished men in 
every age have confirmed it by their testimony ; the former has 
met with no such universal acceptance, but is sufficiently accredited 
to render a brief statement of it proper in this place. 

The ancients remarked that crisis might take place upon any 
day whatever of a disease, but that there were some on which a 
greater number of perfect crises occurred than on any other. Of 
these, the 7th was the principal ; after which, were the 14th, 
the 20th, the 27th, the 34th, and the 40th, which numbers, it will 
be observed, are formed by adding from six to seven days to the 
original number seven. The whole number seven was not added 
at each time, because a week, or the fourth part of a lunar month, 
contains but six days and twenty hours, The intermediate days 
to these were also regarded as next in value as critical epochs ; to 
wit: the 4th, 11th, 17th, 24th, and 31st; or rather, these were 



CRITICAL DAYS. 133 

thought to be occasions on which signs were given that a crisis 
was about to take place; hence they were called dies indicatorii. 
By a further subdivision, other critical days, but of inferior im- 
portance, were established, with the title of intercalary, to wit: the 
3d, 5th, 9th, 16th ; and finally there were the remaining days, the 
2d, 8th, 10th, 13th, and 15th, on which it was affirmed that crises 
seldom or never took place, and which were hence called non-critical 
or vacant. 

Hippocrates, however, in whose writings are found the earliest 
record of this system, did not insist upon it as absolute, but even 
went so far as to admit, that a crisis might take place on the day 
preceding, or on that following the critical epoch, which, as has 
been well remarked, amounts to asserting that a crisis may take 
place on any day whatever ! At the present time, there are few, if 
any physicians, who adhere strictly to the doctrine of critical days. 
Dr. Laycock, who has written with much learning and ingenuity 
upon time as an element of disease, attempts to show that nearly 
all the processes of vitality are marked by regularly remittent or 
intermittent movements taking place in heptal periods, which are 
multiples, or sub-multiples of the number seven, and he adduces 
an immense array of facts relative to the phenomena of generation 
and gestation, to sustain his theory. He shows, for instance, that 
the period of incubation, gestation, of the chrysalis state, of puber- 
ty, in all grades of animated nature, is obedient to the " heptal law," 
and thence reasons chiefly by analogy, and partially from expe- 
rience, that disease must follow the same law. But, admitting the 
wonderful and inexplicable mystery, that the lunar week is the unit 
of a countless number of physiological periods, it does not follow 
that the periods of disease are subordinated to the same law ; the 
question still remains to be decided by direct observation. This 
has not yet been satisfactorily applied. Dr. L. is said to have 
shown, (we have not seen the original Essay,) " that the periods of 
exanthematous fevers are, for the most part, heptal, that the 4th, 
7th, 14th, 17th, are critical days in small-pox ; that the exanthe- 
matous typhus is a twenty-one-day fever ; that shingles run their 
course in fourteen days; and that pemphigus, rubeola, scarlatina, 
&c.,are nil nmrnablo to the general law." M.Grisollos, on the other 

12 



134 TERMINATIONS OF DISEASE. 

hand, who is, perhaps, the only physician who has yet examined 
this subject by means of a rigid analysis of accurately observed 
cases, gives a very different result so far as regards pneumonia, 
the disease, of all others, in which critical phenomena are alleged 
to present themselves with the greatest regularity. Taking the 
thirty-five cases of this disease, in all of which he had noted dis- 
tinct crises, he shows that three of them only underwent the salu- 
tary change upon the seventh day, twenty upon the intercalary 
days, eight upon the non-critical days, and four upon the sixth day, 
which was looked upon by the ancients as peculiarly dangerous ; 
and further, that of ten patients who were trusted to the powers of 
nature, more than one half experienced crises on the non-critical 
days. 

Without insisting that these results, however unfavourable to the 
Hippocratic doctrine, are sufficient to overthrow it, they neverthe- 
less demonstrate its weakness conclusively, and should prevent its 
acceptance until, at least an equal number of cases, noted and ana- 
lysed according to the same severe principles, shall furnish different 
conclusions. Of course, in making the calculation, the position of 
the critical days will depend entirely upon the point from which the 
commencement of the disease is dated. Now, it is clear that the 
result will vary according as the day of the exposure to the cause 
of the disease, or that on which the first uneasiness is felt, or that, 
finally, when the patient takes to his bed, is assumed as the start- 
ing point. There appears to be no general agreement amongst 
physicians, as to which of these dates should be preferred, and 
hence the conclusions at which they arrive, must necessarily be at 
variance. 

We have dwelt upon this subject from a belief that there must, 
in spite of the discrepancies of authors, be some foundation in na- 
ture for a doctrine which is so respectable for its antiquity, and 
which has commanded the assent of many distinguished and inde- 
pendent observers in all parts of the civilized world, and because, if 
true, even in its most prominent features, it ought to have a decided 
influence upon our methods of studying and treating disease. If 
nature, in conflict with disease, tends upon certain days to obtain 
the victory, it becomes us to watch for the contest, — to observe all 



METASTASIS. 135 

the phenomena which mark its successful or unfavourable issue, 
and, while carefully avoiding untimely interference, to be ready at 
a moment's warning to promote the wholesome struggles of the 
system, and to sustain and protect it when ready to sink. 

Metastasis. — When a disease affecting one part of the body, 
disappears upon the occurrence of disease in another part, there is 
said to be metastasis, or change of place. It is evident that this 
term is appropriate in so far only as the newly-arisen disease is of 
the same sort as the original one, and to such cases it was origi- 
nally restricted, cases in which it was believed, that the morbid 
matter was transferred through the circulation to a new seat ; but 
at present it is applied to all instances where there is a substitution 
of one disease for another. 

As examples of true metastasis, the following may be enume- 
rated. It is not uncommon for hssmoptysis or hsematemesis, to 
replace the catamenial discharge, or suppressed hemorrhoids ; for 
pulmonary catarrh to succeed the suppression of chronic diarrhoea, 
or vesical catarrh. Here, the transfer of disease is from one mu- 
cous surface to another. In like manner, a fit of sciatica may sud- 
denly cease, and be followed by neuralgia of the stomach, or by 
asthma. But in other cases, while the disease appears to be essen- 
tially the same, its seat is different : thus, gout and rheumatism, when 
driven from their original position, often attack the pericardium, 
the pleura, or the meninges of the brain, passing thus from a 
fibrous to a serous tissue. Or the successive diseases may be 
seated in tissues having less analogy than these, and display symp- 
toms entirely different ; as when erysipelas leaving the face, is fol- 
lowed by meningitis or peritonitis, or when either of these latter in- 
flammations, or pneumonia, immediately succeeds the repercussion 
of small-pox, measles, or scarlet fever; or when dropsy, or mania, 
follows the spontaneous cure of some chronic cutaneous affection. 
Suppression of the perspiration, milk, or menses, — which, indeed, 
are not morbid secretions, but still, discharges maintained by a vital 
action, and therefore, in their relations to the causation of disease, 
fairly comparable with pathological processes, — when abrupt, is fre- 
quently the immediate forerunner of internal inflammations, drop- 
sies, apoplexy, insanity, &c. 



136 TERMINATIONS OF DISEASE. 

In other and more numerous instances the arrest of some mor- 
bid secretion is followed by the development of a new disease ; 
eczematous discharges from the skin, if suspended, may be fol- 
lowed by anasarca; suppressed gonorrhoea, by ophthalmia ; fistula 
in ano, and pus-secreting sores generally, when dried up, by apo- 
plexy, by pulmonary tubercles in persons of scrofulous constitu- 
tion, or by some internal inflammation or functional derangement. 
Not many years ago the abscesses which formed in the lungs, 
liver, and other organs, after various surgical operations, were re- 
garded as examples of the termination of disease under notice, and 
hence were called metastatic. Their formation is now, however, 
pretty well understood, and is believed to depend upon the transfer 
of pus from the inflamed veins of the wounded part to the several 
organs, and its exciting inflammation and suppuration in these 
latter. 

Such extraordinary phenomena as those just alluded to have 
naturally excited the curiosity of scientific physicians, and led to 
many ingenious attempts at explaining them. These have always 
been made in accordance with the prevalent medical theory of the 
day. The followers of the humoral pathology conceived that "the 
morbific matter after it was concocted and rendered movable, was 
not always evacuated, but sometimes deposited in various parts of 
the body and so produced a new disease," while the vitalists and 
solidists of the modern school assure us that metastasis is nothing 
more than " a transference of irritation " from one part to another. 
That there is in every disease a materies morbi which can be car- 
ried from place to place, like pus in phlebitis, is, however probable, 
yet strictly nothing more than an hypothesis. It is needless to say 
that it is impossible to form any idea of "irritation," and still less 
of its transference. The one doctrine sets a hypothetical substance 
travelling through the system, the other sends upon the same 
journey an abstraction. How far the one is preferable to the other 
let the ingenious decide. 

The important questions are, in what diseases do metastases most 
commonly occur, and under what circumstances ; when do they 
impress a salutary change on the condition of the patient, and when 
increase his danger? It may be answered that they are most apt 



DEATH. 137 

to take place in acute diseases, and in those of uncertain seat, as 
gout and rheumatism; in a direction from without inwards, that is 
to say, from the surface of the body towards its interior, from the 
extremities to the head and trunk ; and that when anything interferes 
with the action of the disease, whether accidental influences, such 
as atmospheric vicissitudes and mental emotion, or attempts to ar- 
rest it by medical art. Original metastases are rarely salutary ; 
yet they are occasionally so ; as when a person predisposed to 
gout is attacked with symptoms of apoplexy which subside imme- 
diately on the supervention of swelling in the great toe. In nearly 
every other case the disease abandons the outworks and assails the 
interior defences, placing life in imminent peril. 

Death. — Physicians as well as unprofessional observers are 
aware that there are two modes of death, the one more or less 
sudden, the other gradual. The former is the least common, and 
either takes place as the termination of some extensive organic dis- 
ease seated in an organ directly essential to life, as in extensive 
cerebral hemorrhage, and other injuries of the brain, rupture of 
the heart, aneurism of the aorta, &c, or else upon some sudden 
exertion during exhaustion from protracted disease, as occasionally 
happens in the last stage of pulmonary consumption, and cancer, 
and in anemia. In these cases death is instantaneous, gives no 
warning of its coming, and takes place without a struggle. 

The phenomena of gradual death vary a good deal in different 
diseases. It is a beneficent provision that the exit out of life should 
oftener be more terrible to the spectators than to the patient ; that 
before the struggle comes which is to separate the body and soul, 
the one should become insensible to impressions, and the other un- 
conscious of suffering. Comparatively speaking, it is very unusual 
for the mind to remain unimpaired until death ; the final struggle 
does not usually commence until coma has thoroughly blunted the 
perceptions. Then a cold and clammy sweat stands upon the 
skin, the respiration grows quicker and shorter; and seemingly 
anxious, but really automatic efforts, are made to expel the mucus 
which chokes up the lungs, and begins to rattle in the throat ; the 
artery at the wrist pulsates more rapidly, but with gradually de- 
creasing regularity and strength, until it can no longer be felt; 

12* 



138 TERMINATIONS OF DISEASE. 

the hands roam about with an uncertain and tremulous movement, 
as if in search of something, and coldness seizes upon the fingers 
and toes and slowly advances towards the trunk. In maladies at- 
tended by much emaciation, the state of the countenance is that 
called hippocratic, after the writer who first described it. It is 
attended by a total loss of the natural expression of the face; the 
skin is dry shrunken and pale, or of a greenish, livid, or leaden 
hue; the nose is cold, sharp, and has its extremity drawn to 
one side ; the eyes are sunken, filmy, and half closed ; the temples 
and cheeks hollow ; the ears shrivelled and retracted ; and the lips 
and lower jaw completely relaxed. 

The duration of these phenomena may not exceed two or three 
hours, or may last for one or two entire days. They are most 
frequently observed at the close of chronic diseases, but are oc- 
casionally met with in what is improperly called sudden death, but 
which is only a sudden and a short disease : we allude to those 
cases of apoplexy, in which death takes place within from ten to 
twenty-four hours after the commencement of the attack. The 
progress of the mortal symptoms is often, in such cases, precisely 
what has been described above. 

By the publication of Bichat's masterly analyses, our knowledge 
of the mechanism of the act of death has been materially increased. 
We shall describe its principal varieties. There is a natural and 
there is an accidental death. The former occurs in old age, and 
is marked by the steady and gradual decay of all the powers of 
life, organic as well as animal. As man advances to the natural 
limit of his earthly existence, he loses one after another his 
means of intercourse with the external world ; one by one all the 
avenues of sense are shut up, the ear grows dull, the eye dim, and 
smelling, tact, and taste are blunted ; his mind, but feebly impressed 
with the objects and events around him, lies dormant, or is moved 
only by recollections of days long past ; his tottering gait, his 
shrivelled and horny skin, his yearning for the fireside and the 
genial warmth of the sun, show how languidly the great functions 
of the circulation are performed ; by degrees his digestion becomes 
impaired, and then the decline proceeds more rapidly; innervation, 
calorification, absorption, and secretion, all become embarrassed 



DEATH BY SYNCOPE. 139 

as the capillary circulation languishes ; sooner or later this function 
ceases, and last of all the heart dies. Death advances from the 
circumference to the centre. Frequently, it is true, old persons 
are cut off by definite diseases, and then their mode of death differs 
in no essential respect from that of the young. 

On the other hand, there are many sudden deaths in which the 
starting point and succession of the terminal phenomena of life can 
be distinctly traced. In these, the cessation of function which 
constitutes death proceeds from the centre to the circumference, 
commencing either at the heart, the brain, or the lungs. These 
three organs appear to be so directly and immediately essential to 
life, as to have been called, figuratively, the tripod on which it 
rests; yet it must not be understood that they alone are thus 
essential, for, as in the case of old age, and in that of many ex- 
hausting diseases, death evidently commences in the parenchyma 
of the organs; the nutritive function is then the first to cease, and 
that, doubtless, because the blood has lost its healthful qualities. 
In various acute diseases, too, it is impossible to analyse the phe- 
nomena of death so as to fix upon the organ in which it originates, 
and equally so to ascertain the cause of its occurrence. The fol- 
lowing account of the modes of death is therefore to be received as 
the expression of what takes place, in those cases only which are 
susceptible of analysis, in consequence of all the organs retaining 
their integrity except the one in which the fatal process takes its rise. 

Death commencing at the heart, or by syncope, is the most sud- 
den form. The pulsations of this organ may be instantaneously 
stopped, and life extinguished like the light of a taper that is blown 
out. They may also decline more slowly and gradually. The 
former happens in wounds of the heart, in ruptures of its tissue, or 
of an aneurismal sac in its neighbourhood, in mechanical obstruc- 
tion to the passage of blood through its cavities, and from debility 
of the organ. In most of these cases the cause resides in the heart 
itself; its function is destroyed by some remote cause affecting its 
mechanism or its vitality. In others, however, its function ceases 
because a sufficient quantity of blood no longer reaches the interior 
of the organ, as in profuse hemorrhages. The brain in common 
with the other organs is deprived of its due supply of blood, and 



140 TERMINATIONS OF DISEASE. 

sensation and voluntary motion are at once suspended ; the lungs 
cease their movements immediately afterwards, and the changes 
of the blood necessary even to the functions of organic life failing 
to take place, those functions can no longer be performed. Dr. 
Williams and others explain one class of deaths from syncope, by 
saying that the heart has lost its " irritability," and the other by 
alleging that it is affected with " tonic spasm," which are nothing 
more than hypothetical phrases expressive of the two facts, that, 
on the one hand, the heart is found dilated, and, in the other, con- 
tracted, after death. These differences may perhaps be thus ex- 
plained. When the heart is found dilated with blood after death, it 
may be presumed that the muscle was either too weak to expel its 
contents, or was actually dead before the flow of blood into it ceased, 
which flow would passively distend it. But when the heart is 
found firmly contracted, after death by hemorrhage, it is evident 
that at each systole having less blood to propel, the bulk of the or- 
gan proportionately diminished until, at last, it failed to propel suf- 
ficient blood for maintaining the action of the nervous system, and 
at that point, and thus contracted, it died. 

Death commencing in the lungs, or by asphyxia or suffocation, 
is owing to some cause which prevents hsematosis. Extensive 
hepatization or induration of the pulmonary parenchyma, tume- 
faction of the membrane lining the smaller bronchia, or the reple- 
tion of these tubes with mucus, false membrane, &c, mechanical 
obstructions of every kind to the entrance of air through the larynx 
or trachea, present examples of this cause. Owing to its influence, 
the venous blood, instead of acquiring, in its circuit through the 
lungs, the qualities of arterial blood, is returned to the left side of the 
heart, and thence distributed over the system, still loaded with the 
excrementitious matters which should have been exhaled, or re- 
vived, by contact with the air. Such a fluid is deleterious wherever 
it moves ; in the brain it destroys voluntary motion, sense, and gene- 
ral sensibility, and induces coma; it impairs even the excited move- 
ments of the respiratory muscles, thus allowing the lungs, the pul- 
monary artery, and the right side of the heart, to become gorged 
with blood; the last-named organ receiving through the coronary 
arteries so imperfect a stimulus, soon loses its power of contracting, 



DEATH BY ASPHYXIA AND COMA. 141 

and then death is complete. This is perhaps the most ordinary 
mode of death in acute diseases, but its progress is often so gradual, 
and it becomes so involved with declining power of the brain and 
heart, as well as with the failure of the nutritive function, that to 
assign to each of these causes its appropriate phenomena is, per- 
haps, impossible. 

Death commencing in the brain, or by coma, is generally owing 
to compression, by depression of the skull, or a tumour of the me- 
ninges, by an effusion of serum, blood, or pus, in or upon the brain, 
or by excessive congestion of the cerebral vessels. This latter may 
arise from a great variety of causes, amongst which may be men- 
tioned alcoholic and narcotic poisons ; but these, perhaps, exert, in 
addition, some injurious impression upon the nervous function. 
Loss of general and special sensation, of voluntary motion, and of 
consciousness, follows the action of any of these causes, but not 
always in the same order. Consciousness is, however, usually the 
first to fail, and then the several senses cease to perceive impres- 
sions distinctly. Such, at least, is the case when death approaches 
slowly, in consequence of serous effusion; but, when more rapid in 
its onset, in apoplexy, for instance, all the functions of the brain 
are suddenly abolished ; nevertheless, as was previously remarked, 
the patient may live internally for many hours, and even days, 
after the stroke, although he is to all appearance dead. This cir- 
cumstance is readily explained by the physiological doctrines of 
the present day. The movements of the organs of respiration, and 
of the heart, which sustain organic life, depend less upon the in- 
tegrity of the brain than upon that of the medulla oblongata, for 
they are instantaneously arrested by pressure upon, or injury to 
the latter, while, as we have seen, they may continue for a consi- 
derable period after extensive disorganization of the cerebral sub- 
stance. Whether, in apoplexy and kindred affections, the pressure 
upon the brain extends ultimately to the medulla by means of 
serous effusion, or whether there is an indirect functional depend- 
ence of the latter organ upon the former, is, perhaps, not well de- 
termined. Certain it is, however, that in death commencing with 
the brain, actual dissolution does not take place until the other two 
of the triumvirate rulers of life have lost their powers. Respiration 



142 SEAT OF DISEASES. 

first becomes embarrassed through paralysis of the respiratory 
muscles ; asphyxia commences, and as it proceeds, the heart be- 
comes gorged, and at last ceases to pulsate. 

Thus, it will be observed, that however the act of death may 
commence, it has one uniform termination, cessation of the heart's 
movements. When the starting point of the mortal process is in 
this organ, the result is generally so immediate, that no percepti- 
ble derangement either of the brain or lungs precedes it ; in the 
exceptional cases, those in which the patient has lived for some 
hours after rupture of the heart, or of the aorta within the pericar- 
dium, the embarrassment of the heart, on reaching a certain de- 
gree, produces syncope, upon which, of course, death closely fol- 
lows. 



SECTION V. 

OF THE SEAT OF DISEASES. 

In the remarks offered in a previous chapter, relative to forming 
a general idea of disease, it was stated, that symptoms are, for 
the most part, to be regarded as evidences of some alteration of 
structure, or composition in the solids or fluids of the body, and 
that, consequently, traces ought to be found of such alteration after 
death. Although this rational anticipation is not always fulfilled, 
yet it is so frequently enough to create a class of diseases distin- 
guished by peculiar characters, and to give rise to the division of 
diseases into local and general, or according to their seat. As 
these, and the most important varieties of each, are apt to be spoken 
of in very indefinite language, it is proper that their real character 
should be explained. 

Local Diseases. — Local diseases are those which are limited to 
an organ or its neighbourhood. They may be either structural or 
functional. In the former case, their nature is demonstrated by 
inspection of the altered tissues ; in the latter, it is inferred from 
some perversion of healthy action. Local diseases may also be 
external or internal. This division corresponds to that between 
medical and surgical diseases, and although sufficiently real for 



LOCAL DISEASES. 143 

all practical purposes, inasmuch as the one class calls for manual 
interference, and the other is usually treated by the agents of the 
materia medica, yet the distinction is wholly artificial in a patho- 
logical view, for the same vital processes are concerned in both ; and 
equally so in a logical sense, for it would be impossible to deter- 
mine exactly at what point the limit between internal and external 
diseases is to be placed. In which class, for example, should be 
arranged those affections of the fauces, rectum, and other mucous 
passages which are near enough to be seen by means of a specu- 
lum, or to be reached with the finger ? 

Structural diseases are often local in a more restricted sense 
than in that of being confined to a particular organ. Frequently 
they involve one only of the elements composing an organ. Thus, 
the lungs, which are made up of bronchial tubes, air-cells, areolar 
tissue, blood-vessels, and serous membrane, may be diseased in 
any one of these textures, to the exclusion of all the rest. The 
termination of the precise seat of the morbid alteration, belongs to 
the department of diagnosis, together with the nature, degree, ex- 
tent, and situation of such alteration. Local affections usually 
occupy a larger extent during their course than at their origin, and 
not only involve more and more of the tissue or organ primarily 
affected, but extend to adjacent tissues and organs, as from a mucous 
lining to the parenchyma, and thence to the investing serous mem- 
brane of an organ. Or, a disease may spread and run its course 
in the same tissue where it arose, as in the case of erratic erysipe- 
las, and other cutaneous inflammations. Gout and rheumatism, 
which are sometimes as strictly local diseases as ordinary inflam- 
mation, may, nevertheless, as we have seen, change their locality, 
and fly from one joint to another, or to some internal organ. 

A local disease is said to be functional, when inspection of the 
organ presumed to be affected, reveals no anatomical lesion. This 
presumption rests upon the accuracy of our physiological knowledge. 
A function is disordered, and we infer that the organ to which it 
belongs is diseased, and in the absence of those signs which indi- 
cate structural lesions, conclude its derangement to be functional 
merely. Our ideas of this sort of alteration, as distinguished from 
that which is physical, are limited almost altogether to the conjee- 



144 SEAT OF DISEASES. 

ture, that all morbid phenomena not directly traceable to some 
physical change, are to be referred to derangement of the nervous 
system, and that not so much because this system is ascertained 
to be capable of producing the diseases in question, as because vital 
functions and nervous forces are equally mysterious, and the hu- 
man mind is prone to attempt the solution of one mystery by means 
of another equally unfathomable. 

In a practical view, nothing can be more fallacious than to refer 
the whole disease of a patient to the organ whose function is prin- 
cipally disturbed. The several parts of the body are bound together 
by a principle expressed by the word sympathy, and which often 
causes one to give evidence of another's disease. Practitioners, 
misled by this equivocal indication, are very apt to address their 
remedies to the wrong quarter, and quite overlook the real source 
of harm. We have seen vomiting in the early months of preg- 
nancy treated by acids and alkalies, and other remedies addressed 
to some imaginary condition of the stomach, without the physician 
ever inquiring into the real cause of the complaint. This same 
symptom, so common at the onset of fevers, afforded one of the 
grounds of Broussais's hypothesis, that all fevers were inflamma- 
tions of the stomach, and led to his treatment by leeches to the epi- 
gastrium, and gum-water internally. Vomiting, too, when a symp- 
tom of cerebral or renal disease is often supposed to proceed from 
gastric disorder. Strabismus and general convulsions are often 
attributed to disease of the brain, when they really depend upon 
the presence of worms, or some other irritant in the bowels. The 
organ which betrays the symptoms of a disease, has frequently as 
little to do with originating them, as the wires of the electric tele- 
graph have with the characters inscribed by its register. The active 
cause of the whole phenomena lies entirely out of sight. 

General Diseases, — By general diseases, is meant those which 
show themselves in various parts of the economy at the same time. 
The modern investigations of morbid anatomists, by demonstrating 
that in various affections previously regarded as general, there is a 
local alteration of structure on which the constitutional symptoms 
evidently depend, and that in several others there are also local 
lesions, although not proportionate in degree or extent to the seve- 



GENERAL DISEASES WITH LOCAL LESIONS. 145 

rity of the general symptoms, led to the denial of the existence of 
diseases whose seat is in no one point, but in the entire system. 
But closer observation, and particularly the examination of the 
animal fluids, have had the effect of weakening so exclusive a doc- 
trine ; and it is now conceded, that since many diseases run their 
course, even to a fatal termination, without leaving any trace of 
local textural lesions, they must, of necessity, be regarded as 
general. 

There are others, again, in which it is true, that local alterations 
are met with, alterations which may be presumed to occasion some 
of the symptoms of inferior importance, but not those whose degree 
expresses the gravity of the affection ; in this case, also, it must 
be inferred that the disease is general. A pertinent illustration is 
afforded by typhoid fever. When the history of this malady was 
first perfected by Louis, its symptoms were all attributed to the 
lesion of the glands of Peyer, which this eminent pathologist de- 
monstrated to be the anatomical character of the disease. This 
lesion consists first in tumefaction, and then, at a more advanced 
stage, of ulceration of the glands in question. Now it was ob- 
served, that in the very worst examples of the affection, in those 
which proved fatal early in its course, the glands of Peyer were 
not ulcerated, but only thickened and hardened, showing plainly 
that some other cause than the condition of the intestinal follicles, 
rendered the disease fatal ; in other words, that it was a general 
disease. Yet, so completely had a false doctrine perverted the 
reasoning powers of medical men, that instead of drawing the ob- 
vious conclusion just stated, they debated among themselves what 
there could be in the swelling and hardness of Peyer's glands, to 
render this condition of them so much more dangerous than their 
ulceration. The same partial mode of reasoning has still more 
lately been employed to explain the salutary action of oil of tur- 
pentine in protracted cases of typhoid fever, and as furnishing an 
indication for the use of nitrate of silver in this disease. These 
agents have been thought curative by means of their healing influ- 
ence upon the intestinal ulcers ; but if the gravity of the disease 
bears no proportion to the number, depth, &c. of these ulcers, such 
an explanation must be rejected as unsound, 

13 



146 SEAT OF DISEASES. 

What has now been advanced respecting typhoid fever, is equally 
true of the other fevers, eruptive, remittent, and intermittent. The 
lesions which constitute their anatomical characters, are not the 
source of their symptoms; they are, themselves, symptoms of 
some pervading vice of the economy, which all observation, 
whether by chemical analysis, or by the study of morbid vital phe- 
nomena, tends to prove must be in the blood. 

There is another class of general diseases in which the lesions 
are also general, in one sense, and in another, local ; general, be- 
cause found to a greater or less extent in every part of the body; 
local, because circumscribed wherever found. Such are tubercle 
and cancer. Their dissemination, their hereditary transmission, 
and, in the case of tubercle, the impairment of the general health 
before any disorganization of the local deposit, prove them to be 
constitutional diseases. Yet, in these, contrary to what takes place 
in fevers, the danger arises not from the general morbid state, but 
from the disorganization of its local products. As long as this pro- 
cess is postponed, the patient enjoys comparatively good health ; 
when once it is established, his life is rarely saved. 

The division of diseases into local and general is, as we have 
seen, founded in nature, yet it is not so absolute as might, perhaps, 
be inferred from the preceding statements. There is hardly any 
local affection, however slight, which does not affect the economy 
to a greater or less extent, either by the pain it causes, or through 
some other and less evident channel. The wound made in a vein 
by a lancet, though trifling in itself, may produce inflammation 
of the lining membrane of the vein ; pus may become mingled with 
the blood, poisoning it, and then giving rise to abscesses in various 
parts of the body. While these things are taking place, and no 
local disease except that of the vein is visible, the whole aspect of 
the patient is that of a person very ill of typhoid fever, and he most 
generally dies. In this case, it is believed that the influence of 
the local disease in the production of the general symptoms, can be 
satisfactorily traced to purulent contamination of the blood, but no 
such connected series of links is to be found in ordinary inflamma- 
tions, none, for instance, which will explain the connexion between 
the local lesions and the general symptoms of pneumonia. To say 






ELEMENTS COMMON TO BOTH CLASSES. 147 

that the latter are produced by sympathy, is to evade the question, 
or merely repeat it in another form. The problem to be solved 
is, how is this sympathy produced ? Reserving an expression of 
opinion upon this point for the next chapter, it is sufficient for our 
present purpose to note the fact, that the division of diseases just 
discussed, is based upon the general features only of the two 
classes, and that there is neither any malady which remains local 
throughout the whole of its course, nor any, however general, 
which does not exhibit its severity in some organs more than in 
others. So that we are not, on the one hand, to refrain from using 
constitutional remedies in apparently local affections, nor to omit 
the treatment of the organs which especially suffer in the progress 
of general diseases. 

Further evidence that the division in question is, to a certain 
degree, artificial, may be drawn from the setiology of the two classes. 
Ordinary inflammations of the internal organs, of the serous mem- 
branes, for example, arise equally from strictly local and from 
general causes ; from wounds or other direct violence, on the one 
hand, and on the other, from the impression of cold upon the sur- 
face of the body. In the former case we are accustomed to regard 
the disease as local, and with apparently good reason ; but in the 
latter, how is it possible for a cause acting upon the skin to excite 
disease in the pleura or peritoneum, except through the medium of 
some general morbid condition ? Nor is the fact of such interme- 
diate state a matter of conjecture merely. Even in the inflamma- 
tions in question, and whether they are excited by direct or in- 
direct influences, there are often premonitory symptoms, such as 
weakness, loss of appetite, chilliness, &c, before any local unea- 
siness whatever indicates the organ about to be attacked ; symptoms 
which it would be most irrational to attribute to a local disease not 
yet in existence. When once the inflammation is set up, its course 
and phenomena are the same, whether it have arisen from direct in- 
jury of the membrane, or from exposure to cold ; and if, in the one 
case, we justly refuse to it the title of a purely local disease, it can 
have no substantial claim to it in the other. 

Again, there are diseases, like gout and rheumatism, in which 
the ordinary phenomena are to a great degree local, but whose 



148 SEAT OF DISEASES. 

course is sometimes such as to prove that they are, in reality, 
general maladies. Both are subject to metastases, and that not 
only from one joint to another, but from the extremities to the 
heart, brain, or other internal organ; and yet gout, shown in this 
manner, as well as by other reasons, to be a constitutional affection, 
is often developed by a cause which has a purely local action, such 
as straining or bruising the great toe. These facts are pregnant 
with profitable instruction to the reflecting physician, and cannot 
be too early nor too deeply impressed upon his mind. 

Another peculiarity may be noticed relative to the seat of .dis- 
eases. Some amongst the local affections possess a sort of morbid 
symmetry ; that is to say, they affect opposite points of the body 
in a similar manner. Inflammation of the brain, of the eyes, of 
the tonsils, the lungs, and the kidneys, is very apt to involve both 
halves of a symmetrical, or both members of a double organ. Or- 
ganic disease of the same parts is to some, though a less extent, 
amenable to a similar law. Disease of the ovaries, mammae, and 
testicles is, on the other hand, usually confined to one of these 
organs. Rheumatism and gout very frequently attack correspond- 
ing joints upon opposite sides of the body, either simultaneously or 
successively, and it has been ascertained that certain changes which 
take place in the arterial tunics, either through inflammation or the 
progress of age, are to be met with chiefly at similar points of this 
system. A still more remarkable illustration is furnished by seve- 
ral cutaneous eruptions which, although of limited extent, occupy 
precisely similar situations on the two sides of the median line, and 
sometimes assume an identical shape, as that of a circle, or of the 
letter/ reversed. 

Besides the two great classes of diseases now considered, there 
is still another composed of what are called diseases of uncertain 
seat. It is usual to include under this denomination intermittent 
fever, gout, rheumatism, the plague, &c, but these, it would seem, 
are more properly ranked with general diseases, because it is evi- 
dent that they not only disturb various functions of the economy, 
but leave behind them tangible and characteristic lesions. We 
would regard as diseases of uncertain seat those only whose symp- 
toms are confined to derangement of the nervous system, whether 



DISEASES OF UNCERTAIN SEAT. 149 

of the intellectual or instinctive functions, of sense or sensibility, or 
of motility; such as insanity, convulsive disorders, and idiopathic 
paralysis. Not but that some of these affections do sometimes 
distinctly depend upon alterations of structure ; the fact that it is 
not always possible to distinguish the cases where such alteration 
exists from such as present no traces of it whatever after death, is 
sufficient to warrant the statement that their seat is uncertain. 
Physiology, indeed, informs us that it is in the nervous system, but 
fails entirely to guide us to the exact point of this complicated and 
mysterious apparatus, whence the morbid influences emanate. 



13* 



CHAPTER II. 

PATHOGENESIS, OR THE THEORY OF DISEASE. 

Every observer of the causes and phenomena of disease is ir- 
resistibly led to form some conjecture in regard to what takes 
place between the action of the one, and the origin of the other ; 
to speculate concerning the part of the system where morbid causes 
first make their impression, upon the manner in which it is made, 
and that of its propagation from one point to another. It seems 
not unreasonable to suppose that if this key to the generation of 
disease were once possessed it would unfold all the secrets which 
now baffle the penetration of pathologists, restricted, as they are, 
to the study of the results of morbid processes ; and that it would 
lead to the discovery of some method of counteracting disease in 
its formative stage, of destroying it in its very germ. Not less 
natural was it for the alchymists to suspect that metallic substances 
having so many qualities in common, might also possess some 
common quality essential to their existence, by the discovery of 
which it would become possible to convert the baser metals into 
gold. But the conjectures, and experiments, and reasonings of the 
searchers after the proximate causes of disease, though they have 
never ceased during a period fourfold longer than those of the al- 
chymists, have never yet produced anything more substantial than 
ingenious fables, which have mischievously drawn off the admira- 
tion of medical men from the sober but fruitful truths of nature. 

It would be a most unprofitable task, so far as regards the ac- 
quisition of pathological knowledge, to present in this place, even a 
summary of the hypotheses which have, in succession, ruled the 
medical world. But, since no physician can hope to avoid either 
forming or adopting some general doctrines of disease, it becomes 
him to know what has been done in this way already, in order that 



MATERIALISTS. 151 

he may not needlessly cherish notions which have long since been 
condemned and abandoned by his predecessors. To obtain an ac- 
quaintance with the splendid or grotesque monuments of folly, 
which, under the name of medical theories, stud the pathway of 
medicine from its origin in Greece to the present day, and which 
served as temples where successive generations of physicians wor- 
shipped, the student must resort to some one of the elaborate histo- 
ries of our science with which learning has enriched it ; in them 
he will find abundant entertainment, and numberless themes for 
meditation. But in the present work, nothing more can be at- 
tempted than to present a brief sketch of several of the most cele- 
brated and permanent of those theories, and which may be said, to 
a great extent^ to include all the rest. 

The first broad distinction of doctrine which strikes the attentive 
reader of medical history, is that between the materialists and the 
vitalists. In all ages, a certain number of physicians have regarded 
the human body as subject to the common laws which govern all 
forms of matter, and to none others. Hippocrates, adopting the 
Pythagorean doctrine, that fire is the source of all matter, and 
that from it were generated earth, air, and water, taught that these 
elements composed the human body; that by their combination with 
the four qualities, hot, cold, moist, and dry, they produced the four 
humours, blood, phlegm, bile, and atrabile, — which, in their turn, 
gave rise to the four temperaments, the sanguine, phlegmatic, bilious, 
and nervous, according as either humour happened to be in excess; 
and that by unnatural combinations with one another, the same hu- 
mours generated various forms of disease. In this theory, which 
was for a long time almost universally received, there was no 
recognition of an immaterial soul, and of its influence upon the 
body; nor even of that principle of life which is common to all 
organized creatures, and which distinguishes them so completely 
from unorganized matter. The putridity of the several humours 
was held sufficient to account for all general diseases, and their 
excess in particular parts, for the origin of local ailcctions. 

The chemical school of the sixteenth century, of which Paracel- 
sus was the great luminary, undertook to explain all diseases by 
the effervescence of salts, the combustion of sulphur, and the coa- 



152 THEORY OF DISEASE. 

gulation of mercury, these minerals being, according to their hypo- 
thesis, the primary elements of the body. In the following age, 
Sylvius and his disciples inculcated a somewhat less rude, but 
equally material pathology. They believed that all diseases de- 
pended either upon an acid or an alkaline acrimony, and that the 
human body was a mere agglomeration of humours in a state of 
perpetual fermentation, distillation, effervescence, and precipita- 
tion ; the result of which processes, when influenced by remote 
morbid causes, was the generation of acrimonious bile or pancrea- 
tic juice, and, through this agency, of disease. As the facts of che- 
mistry accumulated, these doctrines became more or less modified; 
but we have, in the chemical pathology of the present day, the 
legitimate offspring and representative of the old system, which de- 
graded the most perfect work of the Creator to the level of a labo- 
ratory, with its retorts and furnaces, and the physician to a sort of 
chemical manipulator, whose sole business was to neutralize, with 
some product of his own workshop, the imaginary acid or alkali of 
the human system. 

The preceding doctrines were all the expression of a sort of che- 
mical idea, grossly, indeed, conceived by the philosophers of Greece 
and their imitators, and containing a progressively greater amount 
of truth, as they underwent the modifying influence of modern 
chemical science. But there was another purely material medical 
system of a totally different character. This was called the mathe- 
matical. It arose in Italy during the latter half of the seventeenth 
century. According to this hypothesis, "the body was regarded 
simply as a machine composed of a certain system of tubes ; and 
calculations were formed of their diameter, of the friction of the 
fluids in passing along them, of the size of the particles and of the 
pores, the amount of retardation arising from friction and other me- 
chanical causes, while the doctrines of derivation, revulsion, lentor, 
obstruction, and resolution, with others of an analogous kind, all 
founded upon mechanical principles," formed the language of phy- 
siologists and pathologists, and to the present hour are in common 
use under new meanings, and, more frequently, with no definite 
meaning at all. 

The belief in a vital principle as the regulator of healthy and 



VITALISTS. 153 

diseased actions, is of comparatively recent introduction into medi- 
cine. The ancients had, indeed, some indistinct notion of an im- 
material principle resident in the body, and Aristotle went so far 
as to assign to it three modes of manifestation, to wit, nutrition, 
sensation, and intellection, which correspond precisely with our 
modern division of life into organic and animal. But, until near 
the beginning of the last century, the application of this doctrine to 
the generation of disease, does not seem to have been completely 
made. Paracelsus, it is true, had recognised an immaterial power, 
which presides over the digestion and assimilation of food ; and 
Van Helmont attributed to an analogous influence, to which he gave 
the same name, archceus, a control over all the acts of life. This 
power, which he enthroned in the stomach, he represents as the 
governor or prince of numerous subordinate archcei. t residing in the 
several organs ; but he does not well distinguish it or them from 
that independent spirit which is now called the soul. Both of these 
physicians, however, considered the proximate cause of disease to 
consist in some fermentation, or other mechanical change in the 
fluids of the economy. Stahl, on the other hand, rejected all che- 
mical and mechanical reasoning, as inapplicable to vital phenome- 
na, and adopted as their source, a principle which he called anima, 
a term which he, on some occasions, employs in the sense of the 
rational soul, and on others, in that of the principle of life. Ac- 
cording to him, the phenomena of disease are the evidences of a 
struggle between morbific causes and this ani?na, which thus be- 
comes nearly identical with what the ancients, as well as physi- 
cians of the present day, call nature, or the vis medicatrix na- 
turcB. 

This doctrine, so much more acceptable to Christian faith, than 
the cold materialism of preceding philosophers, soon became the 
leading feature in contemporaneous and succeeding systems, and 
in spite of the flood of infidelity which swept over Christendom 
during the last and the present century, it has never ceased to ex- 
ert its influence upon medical doctrine. Hoffman, who was a col- 
league of Stahl, proved that many of the attributes of the anima 
were in reality functions of the nervous system, and Boerhaave, 
the modern Galen, while he retained many of the views of the 



154 THEORY OF DISEASE. 

chemical and mathematical schools, adopted also a large portion 
of the animist creed. His illustrious pupil, Haller, advanced one 
step farther, and attempted to generalize the phenomena of vitality 
by referring them all to contractility and sensibility, the latter of 
which he conceived to belong to the nervous system only, and the 
former to the muscles. Finally, the vitalist doctrine received its 
greatest extension in our own time from the celebrated Bichat, 
who, by a minuter analysis of vital phenomena than had hitherto 
been attempted, referred them to five distinct properties, which he 
denominated, animal sensibility, organic sensibility, animal con- 
tractility, sensible organic contractility, and insensible organic 
contractility. In these several systems, which, it will be observed, 
were little more than successive expansions of that of Stahl, the 
nervous system was regarded, either as receiving the first impres- 
sion of morbific causes, or as the medium through which that im- 
pression was conveyed from one point to another of the body. 

As the two great doctrines of materialism and vitalism led to the 
explanation of the origin of disease, by referring it, on the one 
hand, to purely physical, and on the other, to exclusively vital 
agencies, so the division of the body into fluids and solids gave 
rise to the two opposite theories, one of which placed the source of 
all diseases in the fluids, and the other in the solids of the economy. 
A belief in either of these theories is equally consistent with the 
doctrines of the materialists and vitalists ; for it is evident that 
whether we hold that the functions of the human body are regu- 
lated by chemical, mechanical, or vital laws, we may equally well 
conceive the departure from these laws, which constitutes disease, 
to originate either in the solids or the fluids. Hence we find 
amongst both materialists and vitalists, disciples of the humoral, 
as well as of the solidist school of pathology. 

The humoral pathology, in some form or another, has been every 
where, and in all ages, dominant in the medical world, if we ex- 
cept the last century and a half, during which the theory of solid- 
ism has held a sway, which is fast declining before the disco- 
veries of the chemical pathologists. This latter theory adopting 
Haller's forces, sensibility and contractility, as the only ones ne- 
cessary to life, of course denies them to the fluids of the economy, 



HUMORAL AND SOLIDIST DOCTRINES. 155 

and, by a legitimate deduction from a false premise, concludes that 
the solids alone can receive or manifest the impressions of morbid 
causes. All general diseases, or general symptoms arising from 
local causes, the partisans of this theory attribute to sympathy, an 
hypothesis convenient for explaining everything, which the system, 
without it, would leave unintelligible, and which has perhaps done 
more to postpone the discovery of the laws of morbid phenomena, to 
encourage mental apathy by seeming to solve all difficulties, and to 
give more authority to ingenious expounders of a dogma than to 
- laborious searchers after truth, than any other notion which was 
ever invented by medical philosophers. The solidist doctrine has 
been well described by Sprengel in the following passage: 

" Crises and metastases, which were regarded by the hu moral- 
ists as peculiarly confirmative of their belief, were pressed into the 
service of the opposite school. How, say the solidists, can the 
evacuation of a little blood, urine, fseces, or sweat, explain the es- 
tablishment of health? for the presence of these substances in the 
system is incapable of deranging it. There is a transference of 
action, of irritation, and not of a substance; and the former, they 
gravely assert, nature is much better able to transfer than the lat- 
ter. ... To prove that irritation only is transferred, they cite the 
numerous instances of crisis and metastasis, which consist only of 
a change in the seat of pain, or in some other nervous phenome- 
non. And where there is an afflux of a liquid towards an organ, 
they insist that this liquid may be of various kinds, and that the 
only constant phenomenon is that irritation which precedes the af- 
flux, as is shown by itching, pain, heat, &c. All changes of the 
fluids found after death, or noticed during life, they regard as 
secondary, and appeal to the more constant alterations of the solids, 
revealed by dissection, to sustain their doctrine. In the same way 
they allege that all the symptoms of disease being only so many 
alterations of functions, must proceed immediately from the solids, 
because functions are merely the actions of organs which are of 
course solids." 

According to the humoral doctrine, on the other hand, the origin 
and essence of disease resides in the fluids. " Disease," said Sy- 
denham, " is an effort of nature to expel from the economy a mor- 



156 THEORY OF DISEASE. 

bific matter. Man, exposed to a variety of external influences is 
subject to diseases arising from the introduction and admixture with 
the fluids of noxious particles which diffuse their morbid influence 
over the whole system by means of the blood, and also to various 
fermentations, and even to putrefaction, of the humours when they 
remain too long in the body, and can neither be assimilated nor 
excreted. The peccant and foreign matter thus generated, and 
which would otherwise destroy the whole machine, nature has 
adopted a method of eliminating by means of a series of acts 
which we call symptoms." According to this doctrine, the process 
in question consisted of a peculiar elaboration, or coctioti, by virtue 
of which the noxious particles become capable of assimilation, or 
else are evacuated by some one of the emunctories, thus forming 
a crisis. 

In the midst of these various theories of the origin of disease, the 
rational inquirer must be seriously embarrassed, if called upon to 
adopt some one of them exclusively; but if he has taken as his 
guide the rule of incorporating nothing into his scientific creed, but 
what results from a strict induction of facts, his perplexity need 
not be prolonged. He will then find that each theory rests upon a 
certain number of truths, but none upon a sufficient number to give 
it stability. He must speedily recognise the fact that a large 
number of the phenomena of life are explicable by chemical laws, 
and by them only, but that, at the same time, these laws are main- 
tained in operation by the superintendence of vitality, a power 
which thus not only sustains them, but also upon certain occasions 
subverts them. He must also perceive that some functions are 
performed according to purely mechanical laws, but that their 
moving power is the principle of life, a force possessed of attributes 
different from those of gravity, elasticity, and the other mechanical 
powers. He must admit that, in some diseases, the starting point 
is in the solids, as where they are injured by violence ; but he must, 
at the same time, acknowledge that not a few maladies called gene- 
ral, are directly owing to the introduction of some foreign matter 
into the blood-vessels, and do therefore originate in the fluids. He 
cannot deny that, even in the first-mentioned case, the blood 
speedily undergoes an alteration which is proportioned to the local 



ECLECTIC PATHOLOGY. 157 

hurt, and must, with better reason, be accepted as the cause of the 
general symptoms, than the local lesion itself; and that in the se- 
cond case the original alteration of the fluids is usually followed 
by a more or less general change of structure in the solids. Finally, 
he cannot refuse to believe, that some affections commence by an 
impression upon the mind, the senses, or the general sensibility ; 
but that amongst all of these, scarcely one remains confined to 
the system where it originated, but sooner or later implicates the 
rest. In a word, he beholds in man, a machine indeed, but one 
composed of various materials, which unlike those of other ma- 
chines, are perpetually acting and reacting on one another; not 
only an aggregate of reacting elements, but one endowed with life, 
a power to which the ordinary laws of those elements are wholly 
subordinated, and whose own mode of being and laws are wrapped 
in profound mystery ; not only a living animal, but a rational one, 
possessed of a soul, which, with peculiar faculties and susceptibili- 
ties, is capable of modifying the usual succession of phenomena 
resulting from the co-operation or conflict of the chemical, me- 
chanical, and vital laws which govern the merely animal portion 
of the creature. 



14 



CHAPTER III. 



GENERAL NOSOLOGY. 



In a former chapter the general idea of disease was explained, 
and the existence of separate diseases pointed out. The latter, as 
might be expected from the uniformity of the morbid causes acting 
upon the human organism, and the permanent condition of that 
organism in the human individual and species, possess many points 
common to all of them, and at the same time many which are pe- 
culiar to a certain number only. It results from universal obser- 
vation that while the same disease is never found to affect two per- 
sons in precisely the same manner, yet that different diseases often 
display so close a resemblance in certain particulars, as to prove 
their natural relationship to one another, and to force one to think 
of them as belonging to the same family. This circumstance has 
led to various attempts to classify diseases according to their natu- 
ral resemblances, just as has been done for plants and minerals by 
botanists and mineralogists. Now it is evident that the principles 
upon which such a classification may be based are very numerous, 
as numerous, in fact, as the sorts of resemblance borne by diseases 
to one another. So in botany there are two perfectly distinct sys- 
tems according to which plants may be classified ; the one derived 
from the number of pistils and stamens in the several flowers, and 
the other founded upon the aggregate of the physical qualities of 
individual plants. It is evident, also, that since the object of all 
natural science is utility, that arrangement of plants, minerals, or 
diseases, which regards the relations in which they stand to man- 
kind, must be the most useful and the best. 

Anciently diseases were divided into acute and chronic only, 
but each of these two classes contained a great number of maladies 
having little or no analogy with one another. The same remark 



SYSTEM OF PINEL. 159 

may be made of another division, that into medical and surgical 
diseases. It was not until 1763 that the first systematic classifica- 
tion of diseases, or nosological system, was published by Sauvages, 
of Montpellier, a system which formed the basis of those of Cullen 
and Pinel, the former of which appeared in 1775, and the latter in 
1798. The nomenclature of diseases established by these writers 
is now so thoroughly interwoven with medical language and lite- 
rature as to require at least a passing notice in a work like the 
present. 

In each of the systems just alluded to there was a class of fevers, 
or pyrexia, which, according to Pinel and the prevalent doctrine 
of the present day, includes all the forms of acute disease attended 
with frequency of the pulse, heat of skin, and derangement of the 
functions, without local lesion sufficient to account for these symp- 
toms. The different forms of continued, remittent, intermittent, 
typhus, bilious, and yellow fever, belong to this class. The next 
is the phlegmasia, or inflammations, comprehending all affections 
characterized by local pain, heat, and redness, with or without 
fever, and whether internal or external. Then follow hemorrhages ; 
and then neuroses, or disorders in which the functions of the entire 
nervous system, or of the nervous element of particular organs, 
are deranged. In the class* of neuroses are included all disorders 
of intellection, sensation, and motion, and all deviation from the 
normal action of an organ not dependent upon structural lesions. 
Finally, according to the system of Pinel, there is another class, 
which contains all organic diseases, whether these result from in- 
flammation, from local and accidental injury, or from some per- 
vading vice of the constitution. Those arising from the last-men- 
tioned cause have so close a resemblance to one another, as to call for 
their being arranged in a separate class, as was done by Sauvages 
and Cullen, under the name of cachexies. The various forms of 
chronic tubercular disease, phthisis, marasmus, scrofula, rickets, 
with scurvy, the advanced stages of constitutional syphilis, and 
cancer are comprised in this class. 

The advantages of some nosological arrangement are manifold. 
It lightens the labour of the teacber, as well as of the student of 
medicine, by enabling the former to illustrate his descriptions of any 



160 GENERAL NOSOLOGY. 

disease by comparing it with others of the same natural family, 
and by affording to the latter numerous points upon which his 
memory can fix itself, and which thus recall to his mind the image, 
not of one disease only, but of all those which he has been accus- 
tomed to see associated with it in the lessons of his instructor. It 
inspires both with a desire to know more intimately, the analogies 
which bind together different morbid states, and thus leads to a more 
minute and accurate observation of the phenomena of disease. It 
also renders valuable assistance in therapeutics; for it suggests, 
that in affections not before treated, the physician should apply a 
treatment similar to that which he has found available in others of 
the same nosological class. It is, in a word, the fruitful source of 
many of those discoveries in pathology, and improvements in the 
cure of diseases, which arise out of the perception of their analo- 
gies, a perception which would be far less frequent and distinct, 
were it not for some such arrangement as that in question. 

Yet, it should not be forgotten, that every nosological system is, 
to a great extent, artificial ; and that it is rather an instrument for 
discovering truth, than in itself an expression of truth. None that 
has ever yet been devised, and it may safely be asserted, none yet 
to be invented, can so arrange diseases, that all shall be included 
in perfectly distinct groups. Some will be found which have an 
equally close relationship with several classes, and cannot, there- 
fore, be included in a particular one, without a violation of the first 
principles upon which the classification is formed. " The different 
parts of the body," says Chomel, "are subject to very numerous 
maladies, some of which are common to them all ; as forexample, 
inflammation, organic diseases, atrophy, hypertrophy, alterations 
of secretion and innervation, and the results of chemical or mecha- 
nical injuries. Others are peculiar to certain organs, depending 
upon their very structure, and have, with diseases of other parts, 
only a remote analogy, if any. Amongst the latter may be men- 
tioned the various cutaneous eruptions, aphthous and diphtheritic 
affections, rheumatism, emphysema, rachitis, invagination, varices, 
aneurisms, calculous disorders, and some in which the fluids are 
primitively deranged, as anaemia, diabetes, &c, all of which dis- 
eases are as different from one another, as the structure or compo- 
sition of the solids or fluids where they have their seat, and cannot 



CLASSIFICATIONS OF TEMPORARY VALUE. 161 

be made to enter into our classifications, which, on the other hand, 
are profitably applied to disorders which may affect all parts of the 
economy." 

While these circumstances, with those previously mentioned, 
are carefully borne in mind, it will be seen that they do not, in 
any wise, militate against the utility of nosological systems, but 
ought merely to prevent that blind reliance upon them, which an 
irrational confidence in the authority of their inventors has, some- 
times, inspired. With the progress of pathological knowledge, dis- 
eases which have, from some striking analogies, been placed in a 
certain class, have, by the discovery of some more important rela- 
tionship, been transferred to another class, and thus, every system 
must be regarded as approximative only, to reality, and but tem- 
porary in its completeness. Still, the classes themselves may, 
perhaps, remain permanent, because each contains a certain num- 
ber of diseases well understood, strongly marked, and linked toge- 
ther by unequivocal affinities. This point has been admirably 
illustrated by our philosophical countryman, Dr. Bartlett, from 
whom we borrow this concluding passage : 

" Nearly all diseases will be found to dispose themselves, at dif- 
ferent distances, in what may be called natural, or family groups, 
round certain common centres, each centre, or the circle nearest 
to it, being occupied by one or more of the type species of the 
family to which it belongs. As the affinities between these type 
species and other diseases, diminish in number and importance, the 
latter will recede farther and farther from the neighbourhood of the 
former, until they finally fall without the extreme boundary-line 
which circumscribes the class, and are carried, by new affinities, 
within the limits of some other family. The affinities which de- 
termine these arrangements, constituting the attractive principle, 
in virtue of which, the individual members of each group find their 
appropriate positions, will consist in all the phenomena and rela- 
tionships of the several diseases, and not in any limited or arbitra- 
rily chosen portion of them ; those which are most constant, cha- 
racteristic, and essential, exerting the strongest power. Each class 
or family thus constituted, will be natural and perfect, just, in pro- 
portion to the number and importance of the affinities which bind 
its several members together." 

14* 



CHAPTER IV. 



DIAGNOSIS. 



Every case of disease presents to the physician two grand pro- 
blems to be resolved : 1st, to discover its nature, and 2d, to devise 
its cure. The department of medicine which relates to the former, 
is called diagnosis. This term, derived from the Greek <5ia, yivwtfxco, 
implies a knowledge of differences ; of those, namely, which dis- 
tinguish the affection from all others ; a knowledge, therefore, of 
the disease examined, as well as of those with which it may be 
confounded. Diagnosis lies at the very foundation of the practice 
of medicine ; for it is not possible to discourse about a disease, nor 
even to conceive an idea of it, without knowing in what it consists, 
nor to be sure that the remedies applied to remove it are appro- 
priate, without being able to distinguish it from all others which it 
resembles ; nor yet, to be able to prognosticate its course and ter- 
mination, without an acquaintance with its normal course, its most 
frequent deviations from that course, the complications to which it 
is liable, and the modifications of character which various acci- 
dental influences may impose upon it. To diagnosticate diseases, 
— to separate them from one another according to their peculiari- 
ties, — presupposes such a critical knowledge of them, as only can 
be obtained by making them the subjects of repeated and accurate 
observation. To this process two parties exist, — the physician 
and the patient; that it may result profitably, the former must be 
qualified for his duty, and the latter be in a condition to render 
his assistance. We propose to discuss, as briefly as possible, the 
several points involved in the important relation between the phy- 
sician and the patient, so far as it has for its object the elucidation 
of the history of disease. 



PREPARATORY STUDIES. 163 



SECTION I. 

THE QUALIFICATIONS OF A MEDICAL OBSERVER. 

Strange as it may seem, the fact is perfectly demonstrable, that 
good observers are quite as rare as good reasoners. In science, as 
in religion, there are many " who having eyes, see not, and having 
ears, hear not." From the beginning of time to the present day, 
the same material phenomena have been presented to the senses, 
but in medicine, with comparatively little profit, until a recent date. 
This stationary, or even retrograde condition of medicine, is attri- 
butable, as was explained in the Introductory Essay, to erroneous 
views entertained respecting science in general, and particularly 
medical science. An inferior value has been attached to observa- 
tion, as a means of discovering truth ; and, consequently, the par- 
tial observations actually made, were generally conducted without 
method, and in a spirit wholly opposed to sound philosophy. It 
was reserved to modern times to lay anew, and with imperishable 
materials, the foundations of medical science, and if the labourers 
in this work have frequently employed the stones belonging to the 
old edifice, they have dressed them over again, — laid them with a 
more accurate line and rule, and united them with a far stronger 
cement. 

But while the mechanical part of observation is, to a considera- 
ble extent, a matter of method and training, and is that in which 
later observers have principally excelled, it is not to be overlooked, 
that a sound and liberal education is the best introduction to the 
exercise of this art. This should include, if possible, an acquaint- 
ance with the Latin and Greek languages, especially the former, 
since it furnishes versions of most of the Greek medical writings, 
besides containing a fund of scientific treasure, which has never 
been converted into any of the idioms now spoken. How large 
this collection is, may be inferred from the fact, that until within 
one hundred and fifty years, almost the entire literature of our sci- 
ence was preserved in the Latin and Greek tongues, and that even 



164 DIAGNOSIS. 

during the last century, many medical works of great value were 
published in Latin, and remain untranslated to this day. An ac- 
quaintance with modern languages is even more essential to the 
object in question, which is not the mere acquisition of a right to 
the title of learned, — for however respectable this name, it cannot 
enhance the dignity of that which belongs to the successful ob- 
server of Nature's laws, — but a knowledge of what is already 
known, or believed to be so, and which will serve as a guide to- 
wards paths which lead to truth, and away from those which con- 
duct to error. By such preparatory studies, the investigator learns 
the methods pursued by his predecessors, — perceives their defects 
and advantages, and corrects the former, while he enhances the 
latter. 

It is not the treatises on medical theories, which it is intended to 
recommend to the diligent perusal of the medical investigator, but 
chiefly those which profess to describe disease, or to state gene- 
ral propositions in the form of aphorisms. It is true, that until the 
time of Morgagni, cases of disease were recorded with such mea- 
greness of detail, that little use can be made of them by way of 
comparison with cases observed according to the minute and me- 
thodical system now pursued. Writers contented themselves with 
giving in a few bold touches of the pencil, such an outline picture 
of a malady as was just sufficient to insure its recognition, leaving 
out all those details which would have enabled us, even at this dis- 
tance of time, to examine their cases from other points of view than 
those assumed by themselves. The study of such collections of 
cases as are contained in the works of Morgagni, Andral, Louis, 
and Abercrombie, is one of the best preparations for the personal 
observation of disease, and, if profound and meditative, it will stand 
in the stead of no small amount of actual experience. The advan- 
tages of following the clinical instruction of such a teacher as either 
of these enlightened pathologists, must, of course, be much greater 
than are afforded by the perusal of books alone. If practicable, 
both methods should be adopted, for they will be found to afford 
mutual illustration ; but no one who has not made the experiment, 
can form an adequate idea of the knowledge to be acquired by 
the analytical study of a series of well-recorded cases. The 



STUDY OF CASES THE SENSES TO BE EDUCATED. 165 

most diligent and attentive perusal of a general treatise, however 
well written, cannot furnish one-half the pleasure, nor a tithe of 
the profit that may be derived from this exercise. 

The acquirements and preparation mentioned in a preceding 
paragraph are the more strongly insisted upon, because very gene- 
rally neglected in this country, where the art of observing is igno- 
rantly supposed to consist in a mere passive experience ; although 
every one knows that there are members of the medical, as well as 
of other professions, whose experience does not increase their 
knowledge, because they lack certain original or acquired powers, 
which others possess. 

It is taken for granted that every physician comes to the active 
duties of his profession with a thorough understanding of anatomy, 
physiology and pathology in all its branches, and a competent ac- 
quaintance with the physical methods of exploration, and chemistry. 
No pains need be taken to prove that these branches are quite in- 
dispensable. Whoever hopes to observe disease profitably, with- 
out such aids, will be most painfully disappointed. 

In addition to such preparatory training, it is essential to correct 
observation that the physician be without prejudice or preposses- 
sion ; that he abandon every hypothesis, however respectable for 
its antiquity, or dazzling and attractive in its novelty ; that he shall 
be willing, for the time, to lay aside the pride of reason ; to forget 
the conflicts that are going on in the scientific world ; to bury all 
enmities, except his hatred of error; and to employ all his faculties 
in discovering and recording the phenomena of disease. But to 
these negative qualifications he must add much positive preparation. 
Much of the information he is in search of, is to be acquired by 
means of the senses; and these must be educated. Sometimes, it 
is true, no education can overcome certain natural or accidental 
defects; the near-sighted are of secondary authority in all subjects 
to be investigated by the eye, except where the microscope is em- 
ployed ; the partially deaf can never become good auscultators, 
&c. This is self-evident. But there are other minor defects 
which render a cultivation of the senses almost fruitless, defects of 
which the subject of them is not always conscious, or of which self- 
love would dissuade him from admitting the existence. Many persons 



166 DIAGNOSIS. 

can form no accurate estimate of size, especially of relative size, 
or of symmetry, and thus fail to perceive very considerable distor- 
tions. Others have but little perception of shades of colour, and 
are quite unfit for describing the details of morbid anatomy ; and 
others, without being dull of hearing, have so little ability to dis- 
tinguish sounds from one another, that they profit nothing by the 
lessons of the most accomplished auscultator. 

A medical observer, then, should have all his senses perfect, and 
have so exercised them as to be sure of their accuracy, and also 
of their defects, if they have any, in order that he may know not 
only in what respects their testimony is trustworthy, but in what 
others it should be received with hesitation. This, of course, de- 
mands a degree of moral courage greater than falls to the lot of 
every man. Yet it is, comparatively speaking, a small trial to 
the sincere and honest investigator of the works of nature ; for his 
only object is the discovery of truth, and his errors can therefore 
never be voluntary. To cling to one of them, or seem to do so, 
would be contradicting the whole tenor of his principles and con- 
duct ; it would be setting up an obstacle in the very path he is 
striving to make plain. 

The observer must not only be willing to relinquish error, but 
must exercise that caution and patience which are best adapted to 
prevent his falling into it. The process he is compelled to adopt 
is a long and tedious one, beset with many difficulties, and prolific 
in disappointments ; he is but too often tempted to abandon it, and 
follow out some one of those short cuts to knowledge, with which 
metaphysical subtlety, the dreams of genius, or the frauds of char- 
latanism, have in all ages deluded the indolent and unwary ; but 
he is cheered by the conviction that nature is consistent in her 
operations, and that however obscure they may at first seem, the 
study of them will infallibly conduct to nature's laws. 

The physician, thus fortified by knowledge and principle, when 
he undertakes the investigation of a case of disease, enjoys a great 
advantage over one whose mind is preoccupied by a theory, and 
who is more faithful and ingenious in defending it, than in search- 
ing after truth. If his object were to distinguish himself by the bril- 
liancy of his speculations, his proper place would be in the closet, 



CANDOUR PATIENCE GENTLENESS. 167 

and not at the bedside of the sick ; but as he aspires to the higher 
glory of interpreting the laws of nature, he feels that her secrets 
are to be detected only where she is in action ; he watches and re- 
cords her operations patiently and laboriously, and feels sure that 
an ample reward will ultimately crown his toil. 

Besides these intellectual and scientific qualifications, the physi- 
cian should also be endowed with a spirit of gentleness and kind- 
ness, with such dignity of manner as will insure the confidence 
and respect of his patient, and lead to a full and candid disclosure 
of all the particulars of the case. Whatever interest he may take 
in it as a matter of science, he should impress the subject of his 
care with the conviction that he feels for him the sympathy of a 
man. Especially must the young practitioner, and the physician 
of public institutions, be careful to cultivate this feeling: both are 
too apt to forget that the poverty, the stupidity, the obstinacy, the 
ingratitude, and to some extent, even the vicious habits of their 
patients, are more frequently misfortunes than crimes, and that 
however annoying or revolting in themselves, they cannot absolve 
him from the obligation of showing kindness to those under his 
care ; for an act of beneficence is never so meritorious as when 
conferred upon those who are not in a situation to command it. 



SECTION II. 

THE MODE OF INVESTIGATING A CASE OF DISEASE. 

The study of a case of disease comprises the inspection and the 
interrogation of the patient. The first of these is performed by the 
physician alone, and comprehends a minute survey of all the ex- 
ternal physical characters of the patient, his height, size, colour, 
and expression ; the warmth, sensibility, and motility of the differ- 
ent parts ; his posture, peculiarities of formation, &c. The second 
requires the concurrence of the patient, (who may be more or less 
capable of giving an intelligible account of himself,) or the in for- 



168 DIAGNOSIS. 

mation furnished by his family or attendants, must be accepted in its 
stead. Medical questioning is a difficult art, as much, if not more 
so, than that test of legal dexterity, cross-questioning. The object 
of the latter is to elicit answers favourable to an assumed view of 
a case, but of the former to learn as accurately as possible the 
naked truth. Its only aim should be to obtain a complete history 
of the case from the date of the fifst deviation from health, up to 
that of the examination ; to learn what has actually occurred, 
and not what the physician conjectures ought to have happened. 
A long experience and the closest attention are requisite, in order 
that nothing essential may be omitted, that answers may not be sug- 
gested by leading questions, and that those given at random, and 
out of weariness, be not mistaken for accurate and candid state- 
ments. 

If the patient be intelligent, he will often be able to furnish a 
clear and detailed narrative of his illness, and in that case the phy- 
sician has little to do but to listen patiently, and afterwards inquire 
about such points as have been omitted. More commonly, how- 
ever, it is necessary to propound questions, and obtain an answer 
to each in succession. 

The first question should relate to the commencement of the 
attack, and tend to fix the date of the earliest symptom as accu- 
rately as possible. If the patient be left to do this, he will usually 
assign the first decided change, such as a chill, a fit of vomiting, 
of epistaxis, &c, as the starting-point of the malady ; but in nearly 
every instance, it will be found that other less palpable symptoms 
preceded these ; that there was debility, languor, loss of appetite, 
or restless sleep for several days previously. 

He will also, very probably, be inexact in naming the day on 
which he was taken sick, unless the physician happen to see him 
immediately upon the appearance of the first symptoms. Hence, it 
is well not only to inquire on what day he was attacked, and how 
long he has been ill, but whether on such or such a day immedi- 
ately preceding the one mentioned by him, he attended to his ordi- 
nary business, and if not, what was the last occasion of his attend- 
ing to it. In this manner, the events of each succeeding day, or 
week, according to the duration of the disease, should be recalled, 



TACT. 169 

including the disorders of each function in its turn ; besides which, 
all possible information should be procured, relative to the heredi- 
tary tendencies of the patient, his previous diseases, and his state 
of health and habits for some time immediately preceding the last 
attack. These circumstances once definitely ascertained, the phy- 
sician knows upon what ground he is walking ; he feels as if his 
patient had all along been under his own supervision, and he en- 
ters with alacrity and confidence upon the investigation of the dis- 
ease he is presently to treat. 

In order to be useful, this investigation must be conducted me- 
thodically. There is a faculty called tact, which appears to be 
almost an intuitive perception of the nature of a patient's disease, 
like that singular power by which some individuals arrive at the 
solution of complicated arithmetical problems, without following 
the rules which other men must employ to obtain the same result. 
It is a quality which physicians of large experience sometimes 
possess in astonishing perfection, and which, like judgment and 
common sense, is a natural gift, but like them, also, susceptible of 
high cultivation. However valuable to its possessor this faculty 
may be, it is still liable to great abuse, for it encourages a neglect 
of the ordinary modes of reaching conclusions, and is too apt to be 
relied upon as an unerring guide, which it is far from being, even 
in the most remarkable examples of its development. Being, from 
its very nature, incommunicable, it can never be regarded as a 
means of scientific inquiry, but only as a powerful helper to those 
men of science who are so fortunate as to be endowed with it. If, 
then, some physicians, by the aid of this sixth sense, have been 
able to perceive relations among symptoms, and to predict the re- 
sults of disease, without the necessity of resorting to tedious and 
laborious investigation, it does not by any means follow, that such 
circuitous methods ought to be neglected. They are the only ones 
by means of which scientific truths can be proven, or communi- 
cated to another person, or kept on record for the instruction of 
posterity. 

After having learned the history of a medical case from its ori- 
gin up to the moment of examination, the actual condition of the 
patient is next to be inquired into. The first question should be 

15 



170 



DIAGNOSIS. 



directed to ascertain the seat of his suffering. In local diseases, 
this will usually be the region of the affected organ. In fevers, 
and other general diseases, the most painful part is often that in 
which there is the greatest danger of local complication. All of 
the symptoms furnished by the affected part are first to be noted, 
and then each system, and its functions, claim attention in their 
turn ; but all the particulars relating to each should be exhausted, 
before entering upon the examination of another system or appa- 
ratus, so that no details of importance may be overlooked. 

The following table of the points to be noted in every thorough 
examination of a medical case, will be found useful as a guide. 
Indeed, without some such provision against repetitions and omis- 
sions, it is difficult, if not impossible, to obtain a satisfactory result. 

A. Preliminary Inquiries. 

Age. Profession, and social condition. 

Sex. Habits of living. 

Temperament. Diseases of Parents Relations and Chil 

Constitution. dren. 

Idiosyncrasies. Previous diseases. 

The probable or attributed cause of the illness. 

The mode and period of the attack. 

Premonitory symptoms present or absent. 

The course of the disease. 

The previous treatment. 

TJie present condition of the Patient. 
General appearance. 
Colour of the skin and complexion. 
Expression. 

Degree of muscular development. 
Decubitus. 

Strength. Voice. 

Movements. Convulsions. 

Paralysis. Spasms. 

r- Pain, its characters and 
General and special sensibility. < intensity. 

C State of all the senses. 
C Activity. 
2 Delirium. 

) Illusions and hallucinations. 
V. Coma. 
Duration. 
Dreams. 



The Exterior. 



b. 

The Muscular 
System. 



c. 

The Nervous 
System. 



The Intellect. 



Sleep. 



TABLE OF SYMPTOMS. 



171 



d. 

The Digestive 
Apparatus. 



e. 

Respiratory 

Organs. 

/• 

Circulatory 

Organs. 



The Skin. 



h. 
The Excretions. 



Appetite. 



The Tongue. 



Degree. 

Perversions. 

Thirst. 

( Size and 
j Colour. 
1 Coat. 
C Moisture. 
Salivation, Mastication, Deglutition. 
Nausea. 
Vomiting. 
Pain. 

Sensibility on pressure. 
Stools, 5 Their frequen- 
f cy, quality, &c. 
Piles. 



Abdomen. 



Matters vomited. 

Size of abdomen. 

Tumours. 

Effusion. 

Dimensions, &c, 
of liver, spleen, 
kidneys, and 
bladder. 



The signs revealed by 



The Heart. . 
The Arteries. 
The Veins. . 
Colour. 
Dryness, 
Temperature. 
Sensibility. 
Eruptions. 



Inspection. 
Mensuration. , 
Auscultation. 
*- Percussion. 

Physical examination. 

Pulse. Sounds. 

Development. Murmurs. 



Perspiration. 
Sputa. 
Urine. 
Fa?ces. 
Menstrual fluid. 



Inquire, where appropriate, into their 
Quantity, 
Colour, 

Peculiarities of form, 
Consistence, 
Specific gravity, 
Mixture, 
Odour, 
Taste, and 
" Reaction with chemical tests. 



In conferences with the sick, the plainest language should be 
employed, to the complete exclusion of all technical terms ; to use 
the latter, is a miserable affectation, of which few are guilty besides 



172 DIAGNOSIS. 

those who think it of more consequence, by sounding phrases to 
gain a reputation for wisdom, than to deserve it by a profound 
study of disease. It sometimes happens that a patient, in replying 
to learned questions which he does not understand, in emulation of 
his interrogator makes use of words absolutely without meaning, 
and thus the whole inquisition becomes supremely ridiculous. It 
is often quite impossible to extract a sensible answer from an un- 
educated man, unless he feels at liberty to employ the idiom he is 
most accustomed to. A physician has to learn by experience, the 
meaning of many strange expressions used by the vulgar, and es- 
pecially by foreigners, for in these terms alone is the patient able 
to communicate an idea of his sensations. 

It happens, now and then, that after a close examination of a 
patient in a military hospital, or almshouse, the physician cannot 
discover with what disease he is affected, for the reason that he is 
feigning disease to avoid duty, to obtain privileges, or excite com- 
passion and charity. Impostors of this sort are careful to repre- 
sent affections to whose symptoms physical tests cannot be 
applied. Convulsive and other functional disorders are their 
ordinary models. " To detect the knavery of such persons," 
says M. Rostan, " a dexterous physician may employ various me- 
thods. After ascertaining that the apparent disease is capable of 
being simulated, and how far it is so, he should endeavour to learn 
what motives the patient may have for playing such a part. His 
intelligence should be gauged, and the accordance of the disease 
with the age, sex, habits, condition, fee, of the patient examined. 
But the chief dependence must be upon well-directed questions, for 
the impostor is rarely so familiar with the symptoms of his assumed 
malady, as not to* betray himself, when asked if he does not 
feel certain symptoms foreign to his case, or to contradict himself 
when questioned at different times, regarding the course of his 
disease. His embarrassment is likely to be much increased, when 
he is catechised respecting the causes of his sickness, and the reme- 
dies he has employed. However, he must be closely, but secretly 
watched. Perhaps, the strongest light is thrown upon these 
cases by an examination of the involuntary functions. In diseases 
fn which the pulse ought to be affected, (and there are few which 



FEIGNED DISEASES. 173 

do not affect it,) its condition will often lead at once to a detection 
of the imposture." 

If the entire history of a case cannot be obtained at a single 
visit, and especially if the patient betray signs of weariness, it is 
better to postpone further inquiries until the following day. Much 
harm may be done by an untimely, or a protracted examination. 

The young practitioner should be forewarned, that there are 
many persons, even amongst the educated classes, who grow very 
restive and impatient under the examination which is here insisted 
upon ; for, they cannot comprehend why so close a scrutiny should 
be necessary, when certain popular practitioners form their opinion 
from little more than inspecting the tongue and feeling the pulse. 
They imagine, and not without some plausibility, that the igno- 
rance of the physician must be proportioned to the number of in- 
quiries he makes ; they conceive that it is his business to inform 
them, and not they him. Nothing is so mortifying to a just pride, 
as depreciation of the very qualities or attainments on which a 
claim to merit is founded, and every one who addresses himself to 
the arduous task of investigating disease, must expect such mortifi- 
cation in the early part of his career. But if he wisely prefers be- 
ing thought incompetent, to being really so, he will rarely fail in 
overcoming prejudice at last, and of receiving the applause to which 
he is justly entitled. 

It is not pretended that every case should be subjected to rigid 
analysis ; there are many which demand no such process that they 
may be prescribed for intelligently. Our remarks refer principally 
to those which are somewhat obscure, and especially to all which 
are intended to be recorded. The state of the patient, also, fre- 
quently requires that the examination should be as brief as possible, 
leaving, for the time at least, many things to be conjectured ; for 
his suffering may call for instant relief, or his exhaustion be so 
great as to demand almost undisturbed repose. These are plainly 
exceptional cases. There are others of a different sort. Thus 
delicacy prohibits a very free and direct mode of inquiry in regard 
to many diseases of females, and especially those of an age which 
should be preserved unsullied by the slightest breath of impurity. 
In such cases all communications should be made through an 

15* 



174 DIAGNOSIS. 

elderly person of the same sex, the mother, or some near relative 
of the patient ; and even in the lower walks of life, questions in 
regard to the sexual disorders of the female, should, as far as pos- 
sible, be addressed in the presence of a third person. On the other 
hand, a physician has no right to insist upon the proofs of a well- 
marked venereal affection in the presence of persons from whom 
every motive of honour and humanity would prompt its conceal- 
ment ; nor should this proof be exacted, even from the patient him- 
self, when he seems unwilling to admit its reality, or appears pained 
on account of the suspicion. It is no excuse for the infringement 
of such rules, that there have been some practitioners, of distinc- 
tion too, who have habitually disregarded observances which were 
too delicate for their gross powers of appreciation. 

In cases of extreme gravity, certain questions are liable to 
excite the apprehensions of the patient and hasten the fatal result 
of his disease, even if they do not sometimes turn the balance 
against him. The implicit confidence of a patient in his physician 
is certainly a tribute to be coveted by every man of feeling, but is 
one susceptible of the most cruel abuse. The slightest word of 
encouragement will sometimes arouse the energies, and cheer the 
drooping spirits of the sick ; hence every remark or question which 
even insinuates the incurable nature of the patient's malady, should 
be so indirectly made, and so carefully guarded, as to excite neither 
suspicion nor dread. For a like reason, it is generally prudent to 
decline examining by percussion the chest of a professional brother, 
for his ear will assuredly detect, or seem to perceive, shades of 
difference in the sounds of the two sides, which entirely elude the 
hearing of the operator, and to which the patient will attach an 
importance they do not deserve. It need hardly be added to the 
cautions that have now been given, that no zeal in the cause of 
science will palliate or excuse the needless exposure or fatigue of 
a patient during an examination of the chest, or any other mani- 
pulation, the rude or repeated handling of painful parts, or laying 
the cold hand upon the abdomen or other sensitive portion of the 
body.* 

*The last-mentioned offence against propriety is not one of modern origin. 
It was severely satirized by Martial in an epigram upon his physician : 



RECORDING AND GENERALIZING CASES. 175 



SECTION III. 

THE MODE OF RECORDING AND GENERALIZING MEDICAL CASES. 

The study of disease, pursued in the manner of which an outline 
has been given in the preceding sections, cannot fail to confer scien- 
tific knowledge and practical skill ; but to be rendered in the high- 
est degree available, both for the individual observer and the medical 
profession at large, it must be supported by extensive and accurate 
records of medical cases. The main principles on which this ne- 
cessity rests have been sufficiently elucidated in the introductory 
portion of the present work ; on the present occasion reference 
will be chiefly made to the method of noting individual cases, and 
that of extracting from them general truths. 

The value of a written case depends altogether upon its being 
an exact transcript of nature, not merely of the more striking phe- 
nomena presented to the observer, but of all which are brought to 
light by the interrogatory above proposed, and chronicled as nearly 
as possible in the order in which they occurred. In acute diseases 
the record should be made twice a day, and on both occasions the 
symptoms noted in precisely the same order, so that in making the 
subsequent analysis, each may be found without difficulty, and 
none omitted by the observer. For this purpose, it is con- 
venient to adopt a uniform order in noting the condition of the 
several functions and organs. In chronic diseases such frequent 
records are unnecessary ; and, indeed, whatever may be the form 

Languebam ; sed tu comitatus protinus ad me 

Venisti centum, Simmache, discipuhs : 
Centum me tetigere manus aquilone gelatce ; 

Non habui febrem ; Simmache, nunc habeo. 



I sickened, Simmachus ; to my house you fly 
And bring a hundred students : each in turn 

Witli ice-cold hand on me his touch must try : 
Till then I had no fever, now I burn. 



176 DIAGNOSIS. 

of the affection, the degree of their frequency must be measured 
by the steadiness or variableness of the symptoms. In addition to 
symptoms, properly so called, must be noted all those circumstances 
connected with the origin of the disease, the age, sex, social con- 
dition, habits, constitution, &c, of the patient which have been 
enumerated as subjects for examination, as well as the issue of the 
attack, and if fatal, the results of the dissection. 

After having collected according to this plan a large number of 
cases of a given disease, the most important part of the work still 
remains to be done. The materials out of which the edifice is to 
be built are indeed obtained, but how to use them for this purpose 
remains to be learned. Not many years have elapsed since medi- 
cal philosophers were unable to give any rule for proceeding fur- 
ther; they could only say that facts were to be generalized by 
reasoning, but did not teach in what manner reasoning was to be 
applied to facts in order to elicit truth. While they felt that but 
one conclusion could be legitimately drawn from a given series of 
facts, they plainly saw that different reasoners would deduce from 
it conflicting inferences. 

M. Louis was the first to solve the difficulty. Recognising the force 
of Rousseau's sentiment, already quoted, that truth is in things, 
and not in him who observes them, he perceived that the first step 
towards discovering medical truths was the collection of medical 
facts. Having gathered these he proceeded to extract the truth 
from them. Taking a large number of cases of a disease, he dis- 
sected them, by arranging their phenomena in a tabular form. 
Making a separate table for each case, he registered in one column 
the state of the pulse, in another that of the respiration, in others 
all the remaining symptoms in succession, according to their peri- 
odical occurrence, throughout the attack. It became easy for 
him, therefore, to determine how often a given symptom had pre- 
sented itself in the series of cases, at what epochs, and what other 
symptoms had preceded, followed, or accompanied it; and treating 
every symptom successively in the same manner, it is evident that 
the result could not fail to present an exact representation of the 
disease investigated, so far as the cases made use of were true 
specimens of that disease. So preeminently successful did this 



PHYSICAL EXAMINATION. 177 

method prove in the hands of its inventor, that his works on 
phthisis and typhoid fever stand as monuments of his fidelity, and 
of the uniformity of nature ; for scarcely a single statement or 
conclusion in either has been impugned, during the many years 
that have elapsed since their first publication. For a more com- 
plete illustration of the numerical method the reader is referred to 
the several works of M. Louis, and to the now numerous treatises 
which have been executed upon the same plan. He cannot fail to 
be convinced by them, that any mode of arriving at the laws of 
disease can be successful only in so far as it approaches to that 
which consists in the application of induction and numerical analy- 
sis to medical facts. 



SECTION IV. 

MODES OF PHYSICAL EXAMINATION. 

In the preceding remarks allusion has been made to several 
aids to mere inspection and questioning. They consist partly in 
the methodical use of the senses of touch and hearing, as palpation, 
and immediate auscultation; partly in the employment of certain 
instruments or expedients adapted to assist or improve the senses, 
as mensuration, succussion, percussion, stethoscopic auscultation, 
microscopy, and the use of specula; and partly in the application 
of chemical reagents to detect the composition of the animal tissues, 
fluids, products, and excretions. The use of these several means 
is far from being easy ; they can only be perfectly learned from a 
competent teacher. But as very few students of medicine or 
practitioners enjoy the advantage of such instruction, they should 
all the more diligently obtain, from written precepts and explana- 
tions, the light and guidance which are essential to their employing 
these methods with even a moderate share of satisfaction and suc- 
cess. In the ensuing description we shall first consider the appli- 
cation of the sense of touch to the investigation of disease, including 
pressure and palpation, and the touch or toucher. 



178 DIAGNOSIS. 

Pressure, which determines the resistance of a part by means of 
the hand, and palpation, or the act of handling, whereby is re- 
ceived whatever information the sense of touch can communicate, 
may be considered together, because usually associated in prac- 
tice, although the one may be employed without the other. Pres- 
sure is applied with the whole hand, or with one or more fingers 
only, according to the extent of the surface examined, and the ra- 
pidity of the intended movement. It is employed to ascertain the 
degree of hardness in inflammation and oedema of the cellular tis- 
sue ; the resistance of the walls of the abdomen, when distended by 
tumours, liquids, or gas ; their relaxation after the evacuation of 
the contents of this cavity; and the presence of a solid body with- 
in a liquid abdominal effusion. An example of the sort last men- 
tioned is presented by enlargement of the liver in ascites. By no 
other means can the projection of this organ below the false ribs 
be so well determined. The hand, or the ends of the fingers 
are pressed firmly over the point examined, and then thrust inward 
with a short quick movement ; if the liver lies near the surface, 
the layer of liquid between it and the integuments being suddenly 
displaced, the fingers impinge upon the solid viscus beneath. A 
similar movement communicated to the patella, in effusions within 
the knee-joint, will cause it to strike the condyles with a smart 
shock, and thus indicate the degree of the effusion. 

Pressure renders valuable assistance in determining the seat and 
degree of pain, and often detects its existence where the patient 
does not anticipate that it will be found. Some sorts of pain, those 
which depend upon inflammation, are aggravated by pressure in 
whatever manner it may be made, but others of the neuralgic and 
spasmodic kind are increased by pressure made over a small space, 
and usually soothed by the steady weight ofthe whole hand. The 
pain of abdominal inflammation, and that of colic, are with much 
certainty distinguished in this manner. Pressure, in like manner, 
may show a loss of sensibility in the part to which it is applied; 
pinching the integuments is the best mode of employing it for this 
purpose. It is also a valuable means of ascertaining the activity 
ofthe circulation in the extreme vessels ; for when the blood moves 
languidly the pinkish colour of the skin returns but slowly after 



PRESSURE PALPATION. 179 

pressure made by the end of a finger is removed, while in scarlet 
fever, erysipelas, and other active cutaneous inflammations, the 
eye can scarcely follow the movement of the blood, so instantane- 
ously does it efface the white spot made by the finger. When 
blood is effused by points in the skin, it is sometimes difficult to 
distinguish them from certain papular eruptions ; but the latter 
always disappear on pressure, while the former become more dis- 
tinct, from their contrast with the surrounding surface, which is 
rendered pale by its momentary loss of blood. 

Palpation, when employed to detect superficial departures from 
a normal state, consists merely in passing the hands gently but 
accurately over the affected part, as over the scalp or tibia, for 
instance, in search of nodes. When this, or any other sort of tu- 
mour, has been encountered by means of the expedient in question, 
it is to be further examined by the fingers so as to determine its 
seat, size, shape, consistence, &c. The abdomen more than any 
other region calls for the frequent use of this method, for deter- 
mining alterations in the form and size of its various organs, and 
the formation of morbid tumours within its cavity. When it is 
examined, the patient should lie upon his back, with his limbs and 
trunk so disposed as to relax the abdominal muscles as much as 
possible. The pressure should not be made rudely and forcibly, 
nor with cold hands, for then the muscles become rigid, and ef- 
fectually prevent handling what lies behind them ; but the hands, 
previously warmed, should be spread out upon the surface of 
the body, and with a sort of waving motion press steadily but 
not heavily. If, in spite of these precautions, the muscles con- 
tinue rigid, they may sometimes be made to relax by withdrawing 
the patient's attention from what is going on, either by questions 
or by some remarks unconnected with himself. 

Palpation should always be employed upon the naked skin; but 
as this is not allowable in the case of some females, the physician 
must be content with acquiring an imperfect knowledge of their 
complaint; for the thinnest possible garment interposed between 
the hand and the patient blunts the delicacy of the sense of touch. 
It is true that long experience under these difficulties diminishes 
their evils to some extent. 



180 DIAGNOSIS. 

If the organs to be examined by palpation are deeply seated, or 
of large extent, like the liver and spleen in certain states, and the 
uterus when gravid, the palm of the hand and the fingers do not 
always suffice to indicate their limits. The use of a sensitive sur- 
face which is not accustomed to contact with hard bodies is in 
these cases to be preferred, and none answers the purpose better 
than the inner or ulnar edge of the hand. Pressure is first made 
with the open hand upon the abdominal walls, at some point where 
they oppose only their normal resistance, and then gradually 
nearer and nearer the organ to be examined, until the edge of the 
hand comes in contact with it, when it is usually felt with much 
greater distinctness than by means of the fingers alone. When 
once the position of an enlarged organ, or of a tumour, is thus 
ascertained, its hardness, movability, &c, may be more readily 
estimated, and its limits be accurately marked out by means of 
percussion. 

The common act of feeling the pulse is a mode of palpation. 
To perform it properly, the physician should take the patient's 
hand so that his own index finger shall rest upon the artery, next 
to the wrist, the ends of the other fingers being ranged along the 
vessel, while the thumb presses upon the back of the fore-arm. In 
this manner the hand receives a steady support, and the volume 
and strength of the pulse can be estimated, by using gentle or more 
forcible pressure with the several fingers successively, and then 
with all of them together. It is only by such manipulation that a 
full strong pulse can be distinguished from one that is both full 
and soft.. 

Fluctuation, by which the presence of pus and other fluids is 
discovered in abscesses and cavities bounded by soft parietes, is 
produced by a sort of palpation. The hand or several fingers 
should be applied to one side of the tumid portion, while a few 
smart taps are given to the opposite side, in the case of large col- 
lections, or repeated and quick pressure made when the cavity is 
small. In the former instance, a sort of undulatory movement is 
felt in the liquid beneath, when it is thrown into agitation, and in 
the latter the fingers are sensibly raised through the displacement 
of the fluid by the pressure. This sign should always be sought 



PALPATION THE TOUCH. 181 

for in distension of the abdomen ; where it cannot be produced 
by the method just described, the following plan will sometimes 
succeed. The left hand being firmly pressed against the side of 
the abdomen, the middle finger is raised by the opposite hand, and 
allowed, in its descent, to strike the abdomen smartly ; the vibra- 
tions of the fluid are then perceived by the part of the hand which 
remains at rest. 

When a diseased part is to be subjected to pressure or palpation, 
the corresponding part on the healthy side of the body ought first 
to be examined, in order to obtain a standard of comparison ; for, 
otherwise, it is possible to regard really normal conditions as mor- 
bid. It is well, also, to leave the examination of the seat of pain 
until the close of the visit, so that immediately afterwards the 
patient may enjoy repose ; and even then, it should be conducted 
with all possible gentleness, not only that the patient's feelings may 
be spared, but that he may not contract a dislike for his medical 
attendant. It is cruel, and always unnecessary, to test the ex- 
tremity of the patient's power of endurance ; and it is not always 
unattended with danger, for rude and prolonged handling of in- 
flamed parts aggravates the original disease, or may cause the 
bursting of an internal aneurism or abscess, and so destroy the 
patient. 

Yet the use of palpation upon a single occasion is of little value 
compared with that of its repeated employment in the same case. 
For as its chief utility is in determining the physical characters, 
the number, form, volume, consistence, surface, movableness, and 
contents of tumours, or enlargements of natural parts, it is evident 
that unless the progress of the swelling, its change of consistence, 
its attachments to adjacent parts, its fluctuation, &c, can be esti- 
mated from time to time, the knowledge at first obtained will be of 
little service, either in pointing to the probable period of the termi- 
nation of the disease, or in regulating the kind and activity of the 
treatment. 

The touch or toucher is a mode of palpation applied almost ex- 
clusively to the vagina and rectum. The fore-finger is usually 
employed in this operation, and the physician ought early to learn 
to use that of either hand with the same facility. Although the 

16 



182 DIAGNOSIS. 

vaginal touch is more frequently employed by obstetricians during 
labour, than by any other class of practitioners, yet every physi- 
cian must constantly meet with cases where he cannot dispense 
with the information it is adapted to convey, cases, for example, of 
urino-genital disease, of tumours within the pelvis, &c. Every one, 
therefore, should be acquainted with the mode of practising it. 

The patient may either stand or lie down, and before submitting 
to the examination, should see that her bowels and bladder are 
empty. The finger of the operator ought to be without scratch or 
abrasion, lest he contract syphilitic disease, for it is often met with 
where least expected, and sometimes exists without the knowledge 
of the patient. The finger-nail ought to be short and smooth, and 
the finger well coated with oil, cerate, mucilage, or soap, which 
serves as a guard against absorption, as well as facilitates the in- 
troduction of the finger. If the female is lying down, it should be 
upon her back, near the edge of the bed, with her limbs drawn 
up; the operator should sit facing her, so as to use his right 
hand, unless he is equally adroit with the left. If the patient 
stands, and indeed it is sometimes necessary that the examination 
be performed in both positions, she ought to lean against some firm 
support, and separate her feet from one another, while the physi- 
cian, placing one knee on the ground, supports upon the other the 
arm which he intends using. Whatever be the position of the 
patient, the fore-finger, flexed, is to be passed between the thighs 
until it reaches the perineum, the knuckle is then carried forward, 
and by its means the labia separated, and the finger extended into 
the vagina. Another method is to separate the labia by means of 
the thumb and middle finger, while the index enters between them. 
This finger is then carried backwards and upwards, gradually turn- 
ing until the.thumb is in a position to rest upon the pubis, and the 
other fingers are in contact with the perineum. To reach as far 
as possible, the ulnar edge of the index must press strongly against 
the fourchette, and the remaining fingers be flexed and held down 
by the thumb. 

The finger introduced must now carefully and accurately ex- 
plore the entire surface of the vagina, noting its inequalities, tem- 
perature, sensibility, moisture, and dimensions ; must measure the 



VAGINAL AND RECTAL TOUCH. 183 

size, consistence, position, and irregularities of the neck of the 
uterus, with the state of the os tineas, its degree of dilatation, and 
whether it contains any substance within it; it must also deter- 
mine the bulk, mobility, and weight of the uterus, and at the pro- 
per time execute the movement of ' ballottement ; and, finally, touch 
in every direction the surrounding parts, in order to ascertain the 
condition of the bladder and rectum, and whether any tumour 
exists within the cavity of the pelvis, or whether there is any de- 
formity of its bony walls. 

Touching the rectum is much less frequently employed, but, 
however repugnant both to patient and physician, is often quite 
indispensable. The patient having prepared for the examination 
by evacuating the bowels, should lie on his left side, with the leg 
of the same side extended, and the right limb flexed. The operator 
then anoints his finger, and the anus of the patient, and very gently, 
but firmly, presses the point of the finger upwards, and backwards. 
Prolonged and firm pressure is sometimes necessary to overcome 
the resistance of the sphincter ani, which is usually increased 
when the parts are rendered sensitive by piles, fissures, or a fistula. 
The examination should here be of the same sort as in the vagina; 
search is especially to be made for strictures and pouches, where 
either of these conditions has been suspected, and also into the 
state of the prostate gland and bladder in the male, and of the body 
of the uterus, of the recto-vaginal septum, and of ovarian and other 
tumours, in the female. The introduction of the finger into the 
rectum is of great utility in many cases requiring the use of the 
catheter. Very frequently, indeed, catheterism is quite impossible, 
owing to the point of the instrument catching in the membranous 
portion of the urethrn, until the finger being partially introduced 
affords it support, when it passes readily into the bladder. 

Sounds and probes are instruments adapted to aid the sense of 
touch. They indeed convey the most valuable information respect- 
ing the cavities into which they are introduced; but as they are 
used by the surgeon almost exclusively, a consideration of them 
here would be going beyond the purposed scope of the present 
work. 

A notice of specula [speculum, a mirror) may appropriately follow 



184 DIAGNOSIS. 

that of the " touch," inasmuch as these instruments are chiefly in- 
tended to render visible what by the other method is made tangible. 
There are three in common use, the speculum auris, the speculum 
ani, and the speculum vagina. They all consist essentially of a hol- 
low metallic cone or cylinder, polished on the inside, which being 
introduced into the ear, the vagina, or the rectum, separates the 
sides of the passage from each other, and throws the light upon 
whatever object presents itself at the further extremity of the tube. 
For the sake of convenience the tube may be formed of a single 
piece, or of several, which can be made to diverge after the instru- 
ment is introduced, and thus offer a larger field for inspection. Its 
diameter is of course proportioned to that of the canal for which it 
is intended. 

The vaginal speculum is an instrument of ancient origin. One 
has been found in the ruins of Pompeii, and Paulus iEgineta tells 
us that abscess and ulceration of the uterus may be detected by 
means of an instrument which he calls dioptra. It seems, how- 
ever, to have fallen into disuse, when it was revived by Recamier, 
who employed a simple conical tube. More recently it has been 
modified by dividing the lube longitudinally into two or more seg- 
ments, joined together by means of hinges near the base. By this 
arrangement the further end of the instrument can be expanded, so 
as greatly to enlarge the field of view, while the pressure made 
upon the vulva is not materially increased. The addition of han- 
dles, and of a screw adapted to maintain the further end of the in- 
strument open within the vagina, form the only important improve- 
ments which it has received. 

As the information to be obtained by using the speculum is only 
supplementary to that derived from the " touch," the latter ought 
in all cases to be employed first, for it will often determine the ne- 
cessity of- resorting to the other mode in addition, as well as direct 
attention to those parts which especially require examination, and 
those which may be in danger of laceration or abrasion by the con- 
tact of the speculum. 

The female to be examined should lie upon her back, the hips 
near the edge of the bed, and the feet placed upon chairs far enough 
apart to permit the movements of the physician between them. A 



SPECULA. 



185 



sheet, or some garment, with a vertical slit adapted to the vulva, 
and through which the speculum can be passed, should entirely 
conceal the person of the patient. The instrument having been 
warmed to the temperature of the body by immersion in warm 
water, is then to be well anointed with oil, and the labia being 
separated by the finger and thumb of the left hand, it is presented 
to the orifice of the vagina, and its extremity gently insinuated into 
this canal, in a direction at first downwards and backwards, and 
then horizontally until the neck of the uterus is reached. If a 
branched speculum is employed, it is then to be slightly opened so 
as to bring into view the os tincce, a manoeuvre often attended with 
difficulty, but which can generally be accomplished by repeated 
trials made with steadiness and gentleness. The instrument may 
then be still further dilated, and the parts examined, after being 
carefully wiped with a piece of soft sponge or a wad of cotton 
attached to a handle of proper length. When the light of the sun 
cannot be obtained, that of a candle may be used instead, and its 
effect increased by a bright silver table-spoon held behind it, which 
acts as a concave mirror. Besides permitting the inspection of the 
deep-seated parts of the vagina, the speculum offers the most con- 
venient channel for the introduction of caustics, and other agents 
intended to be very limited in their action. 

The speculum ani differs from that just described, in being 
smaller; and, as the lesions which it is intended to explore are 
situated upon the side of the rectum, such as fistulse, fissures, piles, 
vegetations, &c, it is usually formed of a continuous cone or cylin- 
der, having a lateral slit near its base, by which one-eighth or one- 
tenth of its circumference is removed. The utility of this instru- 
ment is very limited indeed ; it affords but little information not 
equally well learned through the sense of touch, and its introduc- 
tion nearly always gives rise to severe pain. 

The speculum auris is chiefly useful as a means of inspecting, 
more accurately than is possible with direct light only, the state of 
the tympanum, and of the deeper portions of the auditory canal, 
and the character of its obstructions by cerumen, tumours, or 
foreign bodies. It is convenient, also, because when once intro- 
duced, the attention of the operator is not distracted, as in the ordi- 

16* 



186 DIAGNOSIS. 

nary mode, by the necessity of holding the external ear in an un- 
varying position, in order to get even a partial view of the recesses 
of the meatus. 

Mensuration is a method of estimating size, which has been 
employed in the study of disease chiefly since the necessity of 
greater accuracy in describing morbid phenomena became gene- 
rally felt. By it may be learned how far the dimensions of one 
side of the chest exceed those of the opposite side, or what increase 
or diminution of bulk has taken place in a part within a given 
time. The progress of emaciation, the increase or subsidence of 
effusions, the growth of tumours, the return of parts to their normal 
dimensions, and the like, may thus be determined with great pre- 
cision. A correct and practised eye can indeed judge of a smaller 
departure from symmetry than can be determined by linear mea- 
surement ; but it is well to have some scale by which such depar- 
ture, when considerable, can be ascertained, and translated into 
words, so as to avoid, as far as possible, the errors into which de- 
fective vision, immature judgment, or preconceived notions, lead 
many men who have the sincerest desire to be exact. Such a 
scale, too, facilitates the record of the observation, as well for com- 
parison with subsequent observations in the same case, as for the 
use of other observers in similar cases. 

The measurements in question are usually made with a tailor's 
tape, or other inextensible band, divided into inches, and tenths or 
twelfths of an inch. In order to be comparable with one another, 
they must always be made, as nearly as -possible, under the same 
circumstances. Thus on taking the semi-circumference of the 
thorax, it must not at one time be measured at one level, and at 
another time at another level, on one day during inspiration, and 
on another when expiration is complete. The same points must 
be selected on each occasion. In the chest, the most convenient 
is the nipple in the male, and the lower edge of the mamma in the 
female. The semi-circumference at full inspiration, and that on 
complete expiration, should both be measured ; it is evident that 
the mean between the two will represent the average capacity of 
the chest on the side examined. This is the measurement of the 
thorax most commonly employed in practice, because the changes 



MENSURATION. 187 

effected by disease in the whole of either side always affect its 
capacity, and therefore its circumference. Local enlargements of 
the chest, such as depend upon effusion into the pericardium, upon 
emphysema of the lungs, on aneurism of the aorta, &c, are not 
readily susceptible of measurement, but the practised eye detects 
them without much difficulty. 

In measuring the chest, it is to be remembered that there are' 
certain departures from perfect symmetry, which yet do not neces- 
sarily indicate the existence of disease. Thus, the right side of 
the chest is usually more capacious than the left, and its circum- 
ference may measure half an inch more ; lateral curvatures of the 
spine, projection of the ribs of one side near the lower part of the 
sternum, contraction resulting from a former attack of pleurisy, 
and some other partial deformities, are all to be taken into conside- 
ration in estimating the value of thoracic measurements. 

Mensuration may be advantageously applied to diseases of other 
parts ; as to various alterations in the length and volume of limbs, 
to hydrocephalus, and to ascites. In measuring a dropsical abdo- 
men, the level of the umbilicus is the most convenient. The faci- 
lity with which gas forms in the intestinal canal deprives the 
method under notice of much confidence in estimating the progress 
of abdominal effusion, unless, at each measurement, percussion 
shows that there has been no material increase of gaseous disten- 
sion, and unless, also, the measurements repeated on several suc- 
cessive days indicate a progressive augmentation or subsidence of 
the abdomen. In this, as in all other applications of the measuring 
tape, the patient should assume the same posture at each repetition 
of the operation, and one which, when a muscular part is to be 
examined, places it in a state of complete relaxation. 

Various instruments have been contrived for measuring other 
parts of the body, and especially the interior of the female pelvis. 
Many of them are exceedingly ingenious, but by far too com- 
plicated for ordinary purposes. As to pelvimeters, they are re- 
garded by competent authorities as inferior to the hand. The 
index finger, in antero-posterior contractions of the pelvis, can 
reach with ease from the arch of the pubis to the promontory of 
the sacrum, and the distance between these two points can be 



198 DIAGNOSIS. 

marked on it with the thumb, or with a finger of the opposite 
hand. 

Succussion consists in shaking a patient by means of the hands 
applied on each side of the chest, at its base, so as to cause the 
fluid contained in the pleural, or other cavity, to be dashed against 
its sides, and thus produce a sort of gurgling, which may be 
heard at the distance of several feet, or, more distinctly, by apply- 
ing the ear to the chest. It is evident that such a commotion in a 
fluid can only occur when the cavity containing it is also partially 
filled with air, for, if the liquid filled the whole cavity, its motion 
could generate no sound. There can be no vacuum in the body. 
The cases to which this method are applicable, are, therefore, few 
in number, such as bydro-pneumo-thorax, and large tuberculous 
cavities. These conditions are readily enough distinguished with- 
out a resort to so rude a manipulation as succussion, and this me- 
thod, in spite of its antiquity, which is equal to that of medical 
history, is now completely abandoned as a means of diagnosis. 

Percussion, or the act of striking various parts of the body with 
a view of determining the physical changes which have taken 
place in them, is an art of modern invention. It is true that the 
ancients distinguished tympanitis from abdominal effusion by per- 
cussion, but to this application the method was restricted until it ob- 
tained a new inventor in Avenbrugger of Vienna, in 1761. His 
treatise was translated by Corvisart in 1808, and its precepts were 
soon put to the test and approved, its directions modified, and more 
extensive and accurate applications of the method proposed suc- 
cessively, until it has been brought to a high degree of perfection, 
and may be considered, along with auscultation, to be quite as es- 
sential to the successful practice of medicine, as any subordinate 
department of the science whatever. 

The most ignorant vender of wine or beer knows how to esti- 
mate the gradual falling of the liquor in a cask, by the different 
sounds elicited on striking it above and below the level of the 
liquid. The carpenter and the upholsterer know very well whether 
the wall into which they wish to drive a nail, is of brick, or of lath 
and plaster, and in the latter case whereabouts are the studs sup- 



SUCCUSSION PERCUSSION. 189 

porting the wall, merely by the peculiar sounds which these several 
substances render on being struck. Every substance, when thrown 
into sonorous vibration, produces a sound, the tone of which is pe- 
culiar to itself, and every change which takes place in the compo- 
sition of that substance, or in the arrangement of its component 
parts, is accompanied by a corresponding change in its tone. In 
like manner every part of the body when struck, emits a certain 
sound, and always the same sound under the same circumstances. 
Whatever modifies the vibratory power of the part, will also modi- 
fy its tone. But so far as ordinary percussion goes, it has less 
concern with alterations of musical tone than with degrees of in- 
tensity of sound, or the number of vibrations performed by a part 
in a given time ; in other words, with degrees of sonorousness or 
resonance, and its opposite, or what is technically called dulness 
or flatness of sound. The least possible sonorous vibration is ob- 
tained from percussion of a relaxed muscle, or mass of muscles, as 
of the thigh or buttock. The sound thus produced may be regarded 
as the type of perfect dulness. The greatest possible vibration, 
the most perfect type of resonance, is obtained by striking the 
walls of the chest when distended with air, as in pneumo-thorax, 
in which case the sound resembles that of a drum. 

There are infinite degrees between this excessive resonance on 
the one hand, and this absolute dulness on the other. If a part, 
the praecordium for example, emit more sound than natural, on 
being percussed, it is said to be resonant ; not positively as regards 
the most resonant regions, but comparatively as regards its own 
ordinary capacity for generating sound. In like manner, if the 
chest below the clavicle emit less sound than in its natural state, it 
is said to be dull, although more resonant than many other parts 
of the body. 

The inventor of percussion restricted its use to the examination 
of the chest. To elicit sound, he struck the parietes of this cavity 
gently with the ends of the fingers; Corvisart subsequently em- 
ployed for the same purpose the open hand. This was called 
immediate percussion. It answered very well when an extensive 
surface, like one side of the chest or abdomen, was in a condition 



190 DIAGNOSIS. 

to generate a morbid sound, but was of little value when the space 
occupied by dulness was only an inch or two square, and conse- 
quently could not be applied to the accurate measurement of solid 
organs, tumours, &c. 

The great improvement in the art of percussion was that intro- 
duced by Piorry, and which consisted in interposing, between the 
fingers and the part to be percussed, a solid body, whose vibrations 
should accord so nearly with those of the human frame, as not 
to obscure sounds generated by the latter. This body, which 
Piorry termed a pleximeter, (TrX^tfo'w, I strike, and (xs<rpov, measure,) 
was made of a thin plate of cedar, about two inches in diameter, 
for which an ivory plate of the same form was afterwards substi- 
tuted. Percussion, with a pleximeter, is called mediate percussion. 
The sharp sound emitted by wood, and still more by ivory, when 
struck with the ends of the fingers, renders these instruments in- 
eligible ; besides which, their hardness bruises the hand of the 
operator. Both of these inconveniences are obviated, in a great 
measure, by using, as a pleximeter, a piece of caoutchouc about 
two inches long, by an inch wide, and half an inch thick. But 
superior to all of these is the middle finger of the left hand, be- 
cause it is soft, elastic, and not sonorous; because it is adapted, 
by its shape and size, to all the inequalities of the surface of the 
body; and because it is always at hand. The finger possesses 
another advantage, which is that of being able to regulate the de- 
gree of pressure required, according to the resistance of the parts 
percussed, and the distance from the surface of the solid body to 
be examined. This is of great consequence in percussion of the 
abdomen. The finger, too, can be more accurately applied to the 
integuments, than an artificial pleximeter, which is an important 
consideration; for the presence of air between this instrument and 
the skin entirely alters its sound when struck. 

The fingers of the right hand are generally used to percuss; 
but, except when the dulness is great, a single one of them, the 
medius, is quite sufficient. The fingers should be flexep 1 nearly at 
a right angle at their middle joint, and their ends brought accu- 
rately to the same line. In striking the pleximeter, the force of 



PERCUSSION. 191 

the blow should never exceed what is necessary for bringing out 
fully the characteristic sound; whatever is more than this fa- 
tigues the patient, and is painful to the physician's hand. On 
this account, the blow must be short and quick, and the fingers 
raised as soon as it is given. The whole movement of the right 
hand should be from the wrist downwards, the forearm remaining 
quite motionless, and placed in the most convenient position for 
affording a proper support to the hand. This movement is 
not readily acquired by every one, but its acquisition is quite as 
essential to the delicate and satisfactory performance of percussion, 
as a similar control of the hand is to accurate and brilliant execu- 
tion upon keyed instruments of music. Nearly all who are expert 
in this art succeed in eliciting clear and loud sounds by a very 
slight, and apparently gentle, movement of the hand, and, in a 
great majority of cases, percuss with one finger only. 

The value of percussion, in disease, depends altogether upon a 
knowledge of the sounds which the same method produces in health. 
Hence a preliminary step in its study is the percussion of perfectly 
healthy persons at various ages, by which will be learned the nu- 
merous modifications in its results, imposed by the progress of life, 
the sex, and the embonpoint of the patient, and yet perfectly com- 
patible with a normal condition. For a similar reason, in examining 
a case of disease, percussion should be practised first upon parts 
presumed to be sound, and a gradual approach made to the sup- 
posed seat of the disease. In the chest, for example, the side 
which is free from pain, &c, should first be examined, and per- 
cussion made, comparatively, at exactly corresponding points of 
the opposite sides, until the whole extent of each is explored. In 
health the sounds furnished by the opposite sides of the thorax are, 
for the most part, identical ; the heart destroys this equality in a 
small space in front. Hence the slightest disparity should lead to 
a more minute and careful examination of the parts where it is 
detected. 

The surface examined should either be quite naked, or covered 
only with thin flannel or linen. Cotton tissues are said by Andral 
to deaden the sounds. But in this country they are so universally 
worn, that the physician is constantly obliged to receive the results 



192 DIAGNOSIS. 

of percussion as modified by them. We have not found a cotton 
garment to interfere seriously with percussion, when the precaution 
is taken to stretch it tightly and smoothly over the skin. Moreover, 
the region of the body in which more than in any other it is im- 
portant to detect the slighter shades of sound, that bordering upon 
the clavicles, is nearly always accessible, even in the most delicate 
females, without the intervention of any garment whatever. 

During the examination strict silence in the chamber should be 
enjoined. The patient should assume an easy posture. If the 
front of the chest is to be examined, he should sit upright, leaning 
against the back of a chair, or else lie upon his back in bed ; if the 
posterior part, he should either sit up in bed, resting his folded arms 
upon his knees, or, if able to do so, and a male, sit astride a chair, 
leaning with his arms crossed upon its back ; if the side, the cor- 
responding hand should be placed upon the top of the head, or 
supported at the proper level by an assistant, and that, whether the 
patient be able to sit up, or can only turn upon the side opposite to 
the one percussed, while in a recumbent posture. When the 
strength of the patient permits, it is sometimes important that he 
should go upon his hands and knees, in order to ascertain whether 
effusions in the abdomen and chest obey the laws of gravity, and 
therefore whether they are limited by adhesions, or contained in 
a sac, &c. ; and where debility, or any other cause, prevents this 
posture from being assumed, the patient should, in the cases re- 
ferred to, be required to change his position from side to side, in 
order to permit the change of relation between the liquid and the 
part percussed to take place. 

Auscultation in medicine is the art of listening to the different 
sounds produced within the body. Its object is to determine the 
condition of an organ in which the natural sounds are altered. It 
is, therefore, a method of diagnosis. The chief applications of 
this art are to the study of diseases of the respiratory and circu- 
latory apparatus. It is also employed in obstetrics to determine 
the existence and position of the faztus in utero. For the discovery 
of this precious art, as applied to the heart and lungs, we are 
wholly indebted to Laennec. Not only did he lay the foundation 
of our knowledge respecting it, but his indefatigable industry and 



ORIGIN OF AUSCULTATION. 193 

ardent zeal, the best evidences of his exalted genius, brought it 
very nearly to that degree of perfection which it has now attained, 
and which renders it one of the most valuable instruments ever 
devised by the skill of man for bringing light out of darkness, and 
harmony out of confusion. 

Laennec thus describes the accident which led to its discovery. 
" In 1816, I was consulted in the case of a young lady, who pre- 
sented general symptoms of disease of the heart, but whose embon- 
point prevented any satisfactory results from being obtained by 
percussion and the application of the hand. The age and sex of 
the patient rendering it improper to apply my ear to the chest, I 
happened to remember a well-known fact in acoustics, that if the 
ear be placed against one end of a beam, it can distinctly hear even 
the scratching of a pin at the opposite end. It occurred to me that 
this property of bodies might be made available in the case before 
me. I accordingly took a quire of paper rolled up very tightly, 
and setting one end of it against the precordial region, applied my 
ear to the other. I was not less surprised than delighted, when I 
heard the pulsations of the heart more clearly and distinctly than 
I had ever done before by the direct application of the ear to the 
chest. I at once conjectured that this expedient might become an 
useful method, and applicable to the study of the sounds of the 
heart not only, but of all movements capable of producing sound 
within the cavity of the chest, and consequently to the investiga- 
tion of the respiration, the voice, the different rhonchi, and perhaps 
even to the fluctuation of a liquid effusion in the pleura or pericar- 
dium." 

Laennec soon submitted this conjecture to the test of experi- 
ment ; he believed that his surmise might be an interpretation of 
nature, and to nature he betook himself for its confirmation ordis- 
proval. Every trial he made of it strengthened the demonstration 
of its truth, and he soon arrived at what was then naturally re- 
garded as an astounding result, that his new method " was capa- 
ble of rendering the diagnosis of nearly every disease of the lungs, 
the pleurae, and the heart, more certain, and more minute, than 
perhaps even those surgical diagnoses established by means of the 
sound, the probe, or the finger.' 1 

n 



194 DIAGNOSIS. 

The value of auscultation might be illustrated by innumerable 
instances, but in this place a few of the more general examples of 
its utility will suffice. It serves to distinguish at once, organic from 
functional and sympathetic disorders of the respiratory organs and 
of the heart ; to detect serious lesions in the former of them, while 
yet their functions seem almost unimpaired ; to unmask such dis- 
eases when hidden by some other affection, such as coma, delirium, 
&c, and reveal them when existing in children, and other persons 
incapable of describing their sensations ; to determine the precise 
situation of the lesion, its stage, and extent; to indicate the proper place 
for applying certain therapeutic agents, as well as to prevent error 
in their selection, by establishing that essential preliminary to all ra- 
tional treatment, a correct diagnosis ; and in consequence of con- 
ferring this superior accuracy in other respects, to improve and 
perfect prognosis. 

If auscultation is of itself so fruitful of good, how much more 
valuable is it when combined with percussion, and all the other 
physical methods, as well as functional signs, which elucidate, or 
are furnished by, diseases to which it is applicable. In this com- 
bination it should always be judged of and employed, and never 
isolated, and set up as an infallible oracle. It is to be respected as 
one of the greatest of those counsellors, " in the multitude of whom 
there is safety." 

Auscultation may be either 'mediate or direct; that is to say, 
may be practised by means of a stethoscope, or by the direct ap- 
plication of the ear. The former was the plan adopted and recom- 
mended by Laennec, to the exclusion of the latter, which is now 
employed, unless in exceptional cases, by nearly all good ausculta- 
tors. The advantages of the stethoscope are chiefly these. It can 
be applied to the clavicular, axillary, and intra-scapular regions, 
and over arteries, where it is difficult, if not impossible, to adjust 
the ear; it conveys the sound generated within a very limited 
space, and therefore answers very well for localizing many pul- 
monary and cardiac murmurs, much better than the ear, which 
receives sounds not only from the part immediately beneath it, but 
from a considerable portion of the region with which the side of the 
head is in contact, because the bones of the head form an excellent 



METHODS OF AUSCULTATION. 195 

conductor of sound ; it prevents the necessity of such an approach 
to females, as, in some instances, offends their delicacy, and it ena- 
bles us to avoid immediate contact with filthy persons, and those 
labouring under contagious diseases. 

On the other hand, the sounds heard by direct auscultation, and 
especially the moist ronchi, are more distinct ; if by this method 
individual murmurs are not so perfectly isolated as by the stetho- 
scope, the ear of the skilful auscultator can distinguish between the 
near and the remote, and is able to listen to a single one to the ex- 
clusion of such as are associated with it ; direct auscultation is 
more applicable to infants than the stethoscope, which usually 
alarms them ; and the objection to its employment with scrupulous 
females and filthy patients, may generally be obviated by inter- 
posing a thin garment or a clean napkin between the ear and the 
skin. 

On the whole, although direct auscultation conveys all essential 
knowledge of most cases of pulmonary or cardiac disease, yet 
there are cases in which the other method gives a superior pre- 
cision and certainty to that knowledge. Such are those of valvular 
disease of the heart, in which the stethoscope, and especially the 
flexible one introduced by Dr. Pennock, of this city, leads to a 
much more accurate diagnosis of the particular orifice affected, 
than can usually be obtained by the unassisted ear. Excepting 
infantile cases, this instrument is applicable to all in which direct 
auscultation may be used, and to some, as we have stated, where 
the latter method is inexpedient or unsatisfactory. If then, it were 
necessary to choose the one and reject the other, the stethoscope 
should be retained, but since physicians are not reduced to this al- 
ternative, they ought to learn to employ both, so as never to be 
embarrassed by the peculiarities of a new case. 

Although it is preferable that the part ausculted should be 
naked, yet this is not an essential condition, except for the learner. 
Experience teaches what allowance must be made for the influence 
of the several sorts of garments worn next the skin, in obscuring 
and altering the sounds ; but were a beginner to receive his first 
notions of respiratory, and other murmurs, through such media, 
he would ever afterwards be at a loss what portions of the mixed 



196 DIAGNOSIS. 

sounds to refer to their respective sources. His first essays should 
always be upon the naked body, first of healthy, and then of dis- 
eased individuals. So long as the garment is of close texture, and 
applied smoothly to the surface, its thickness does not seriously 
interfere with the transmission of sound, but when starched or 
otherwise stiffened, so as to admit of the entrance of air between 
it and the skin, or of much motion, it occasions noises which may 
entirely mask those generated within the body. 

In order to auscult satisfactorily, the physician should accustom 
himself to use either ear, so that if both are sufficiently acute, he 
will be ready to proceed with the examination on whichever side 
of the patient he may happen to stand. He will generally find, 
however, that he hears better with one ear than with the other ; 
hence whenever he feels doubtful in regard to a sound he should 
always listen to it with his best ear. If a stethoscope is employed, 
it should be held between the finger and thumb, its larger extremity 
resting firmly upon the surface of the body ; when steadily placed, 
the fingers may be withdrawn, and the instrument supported by 
the pressure of the head. Without these precautions it is impossible 
to obtain a clear perception of stethoscopic sounds. It is equally 
necessary that the auscultator should not place himself in such a 
constrained position as will cause an accumulation of blood in his 
head, in the stooping posture for instance ; this caution is very 
important to be observed after meals. 

The general rules suggested for practising percussion in all that 
relates to the posture of the patient, the order in which the sound 
and diseased parts are to be examined, the accurate comparison 
of opposite sides in pulmonary affections, &c, are equally applicable 
to auscultation. But since there are several kinds of phenomena 
appreciable by auscultation, they should be studied in regular 
order, according to an uniform plan. Thus, in examining the 
thorax, the respiration first, then the rhonchi, and then the voice, 
and each as modified by a fuller, faster, or slower breathing, by 
speaking and coughing more or less loudly, &c, ought to be passed 
in review. When the condition of the heart is investigated, there 
must be estimated, besides its impulse, the seat, the intensity, the 
extent, the rhythm, and other peculiarities of the natural sounds, 



AUSCULTATORY PERCUSSION. 197 

and then the same qualities of those which are abnormal, and 
finally all of these as influenced by the state of the respiration, and 
the movements or repose of the patient. So in obstetrical auscul- 
tation ; the placental murmur, the sounds of the foetal heart, those 
produced by the movements of the child, &c, all require to be ex- 
amined in succession, and in various conditions of posture, excite- 
ment, &c, of the mother. 

Auscultatory Percussion. — In ordinary percussion the vibrations 
of the part which is struck, reach the ear through the intermediate 
air, and the sound produced is not more particularly characterized 
than as either dull or sonorous. But two ingenious physicians of 
New York, Drs. Cammann and Clark, have invented a method by 
which the sound of percussion is conveyed to the ear by a solid 
stethoscope, and in which every organ is considered as emitting, 
when percussed, a sound peculiar to itself. Thus, when the ste- 
thoscope is applied, and percussion is made upon the body, near 
the further end of this instrument, a different sound is perceived 
according as the stethoscope is placed over the heart, the liver, the 
lung, a collection of fluid in the abdomen, a bone, &c. In mark- 
ing out the limits of an organ, it is alleged that the sound peculiar 
to that organ, can be heard beyond the line at which ordinary 
dulness ceases, and, consequently, that its boundaries can be more 
accurately determined than by the usual method. It is also claimed 
that this combination of percussion and auscultation is capable of 
determining the precise line of separation between two solid organs 
which press against one another, as when a solidified lung is in 
contact with the heart, or is separated from the liver by the dia- 
phragm alone. This very ingenious method, of which an account 
was first published in 1840, we were lately assured by one of its 
inventors, continues to be practised by them with success ; but it 
does not appear to have been extensively employed as a means of 
physical diagnosis, because, perhaps, simple percussion has been 
found so generally sufficient, that pains have not been taken to test 
the value of the proposed substitute. 

In conclusion; the object of percussion and auscultation being to 
discover the degree and extent of the solidity of a part, and the actual 
condition of, or the changes that have taken place in, the natural 

17* 



198 DIAGNOSIS. 

cavities, and the contents of organs, by means of the sounds which 
they are capable of producing, it follows that whatever expedients 
are best adapted to develope these sounds and render them more 
distinct, are those most apt to lead to the desired results. A clear 
apprehension of the mechanical principles on which the rationale 
of auscultation rests, and some degree of ingenuity on the part of 
the observer, will readily suggest to him many variations in the 
mode of applying this art, and as his experience increases, he will 
attain to greater ease and rapidity in his examinations, and pre- 
cision in his diagnosis. 

The use of the microscope in pathological investigations is 
an art so difficult, that none but those who have especially, and 
for a long time, cultivated it, can depend upon the correctness of 
their observations, or estimate justly the phenomena they witness. 
On this account it can never become, like the methods heretofore 
discussed, of habitual employment in ordinary practice, even 
were the points of pathology which it is capable of elucidating 
much more numerous than they really are. The sphere of use- 
fulness of the microscope is almost entirely limited to distinguishing 
the proximate elements of the body from one another, where these 
latter actually possess marked characters; but, according even to 
some of those most expert in its management, it is incapable of show- 
ing any differences between the particles of some very dissimilar bo- 
dies, such as pus and mucus, or tubercle and cancer. Without grant- 
ing that such difficulties exist in the degree alleged, or that they are 
insurmountable, it must still be admitted that the value of the micro- 
scope is less questionable as a means of detecting crystallizable pro- 
ducts in the urine, when they exist there in such small quantities as 
to elude chemical analysis; or animalcules in the sperm; or, when 
employed in the simple form of an ordinary magnifying glass, as 
a mode of detecting, or identifying, the various minute insects and 
entozoa which infest the human body. Whatever pathological re- 
sults have been obtained through the microscope will be mentioned 
hereafter. 

Reflections similar to the above may be made in regard to the 
application of 'chemistry to the study of disease. Chemical methods, 
properly so called, those, namely, which consist in subverting the 



THE MICROSCOPE CHEMICAL ANALYSIS. 199 

natural affinities of organic compounds, are of very limited utility 
in revealing morbid phenomena which escape the senses. It is 
true, that of late years many theories of disease, or of particular 
diseases, have been proposed as the results of chemical investiga- 
tion ; but none has yet been advanced which could long stand the 
test of experience. It may even be possible that a general and true 
theory of disease is destined to grow out of organic chemistry ; but, 
up to the present time, this science has contributed but sparingly 
to the elements of medical diagnosis and prognosis. It does, in- 
deed, furnish the means of ascertaining whether certain normal 
constituents of the secretions are in excess, or deficient, and whether 
or not certain abnormal constituents of these fluids, and of the 
blood, are present. Thus it shows by very simple processes, 
whether they are acid, alkaline, or neutral ; whether the urine 
contains sugar or albumen, or uric or phosphatic salts, or the 
colouring matter of the bile ; but this knowledge, useful as it is, 
falls far short in value, of that obtained by an analysis of the 
blood, not that analysis which destroys the substance it examines, 
and is in the true sense chemical, but that which by a purely me- 
chanical operation separates from one another, and weighs, the 
proximate elements of the blood, its fibrine, globules, water, and 
albumen, and shows which of them preponderate, and which are 
deficient in particular diseases. The processes and operations 
here referred to are easily learned, and may be practised by any 
physician of moderate attainments. The destructive processes, on 
the other hand, can only be conducted by professional chemists, 
and require a degree of skill and accuracy in manipulation, and 
a measure of scientific attainments which very few possess. 



CHAPTER V. 



PROGNOSIS. 



Prognosis is the foreknowledge of the course, events, or termi- 
nations of disease. It is not, in one sense, essential to the treatment 
of disease, because it relates only to the future; but its incidental 
value is often very great, inasmuch as it affects the domestic and 
civil relations of the patient, inspires him with a hope of recovery, 
or by assuring him of the impossibility of such an event, disposes 
him to make those preparations for his change which religion en- 
joins, and affection demands. Upon no other subject is the opinion 
of a physician so often required. It makes but little difference to 
the patient whether his malady is of one nature or another, or is 
called by one or another name, except in so far as a knowledge of 
its name and nature gives him some notion of its gravity, duration, 
and probable issue. The physician is concerned with the present, 
the patient looks constantly to the future. All the questions that the 
former asks, relate to what has happened, or is taking place ; all the 
inquiries of the latter refer to what he may expect to suffer or escape. 
From the very commencement of the attack, the friends of the patient 
are less concerned to know his disease, than the probable duration 
of his confinement, and some opinion upon this point the physician 
can scarcely avoid expressing. In proportion to the positiveness 
of his prognosis, and the accordance with it of the result of the 
attack, is the honour in which he is held, and certainly with good 
reason, if his opinion have been anything more than a lucky guess. 
For if diagnosis be difficult, and therapeutics uncertain, prognosis 
is both, and in a twofold degree. That it is found to be so in 
practice is shown by the extreme wariness and hesitation of men 
of sound experience in predicting the issue of a disease, and the 
readiness and confidence of young and ignorant practitioners, in 
foretelling the event of every affection they have to treat. 



DIFFICULTIES OF PROGNOSIS. 201 

It is peculiarly unfortunate, that nearly all positive indications 
are of a fatal tendency ; such as have a contrary meaning, are 
lamentably few and obscure ; so that whoever will undertake to 
promise, without qualification, a cure even of the mildest disease, 
is possessed of more boldness than the occasion warrants. A phy- 
sician, therefore, who is sensible of the many difficulties that en- 
viron this subject, ought rather to prefer relinquishing all claims to 
being thought a prophet, that he may enjoy the credit due to his 
candour. While he points out the symptoms that appear to him 
propitious, he will impress it, at least upon the friends of the pa- 
tient, that his utmost skill does not extend beyond the indication of 
probabilities ; and this he is bound to do without in the least im- 
pairing that hope of recovery which has sometimes, even in appa- 
rently desperate cases, been sufficient to overcome the disease. 
There are, indeed, not a few instances in which the medical tact 
which has been spoken of, may stand the physician in good stead. 
He may perceive, in certain symptoms, a significance which he 
cannot account for nor analyze, and often his predictions may be 
verified. But such a quality is more frequently possessed by nurses 
and old women, who have long been used to watch the sick by 
night and day, than by the physician who sees his patient but for 
half an hour, perhaps, in the whole twenty-four hours. This 
faculty, moreover, is peculiar to the individual, and cannot be 
taught; its objects and operations, consequently, cannot be regarded 
as belonging to medical science. 

Scientific prognosis, on the other hand, is founded on diagnosis; 
the disease under observation must first be made out, before any- 
thing can be predicted of it with tolerable certainty, at least during 
its stage of increase. Yet prognosis demands greater skill and ex- 
perience than diagnosis ; for often it is very easy to determine the 
nature of a disease, but quite impossible to foresee its termination ; 
because, one that is mild in the beginning, may, during its course, 
become violent or malignant. No human sagacity can anticipate 
the numberless influences for good or for evil, which may come 
into play, increasing the activity of a disease, or causing its exten- 
sion to an important organ, or changing its type from one capable 
of supporting active treatment, to one in which no treatment will 



202 PROGNOSIS. 

be serviceable. A long and true experience is necessary for learn- 
ing all the forms of a given disease, all its tendencies, all the acci- 
dents which may alter its course ; a whole lifetime is hardly suffi- 
cient for accumulating a mass of facts adequate to the solution of 
many such complex problems which daily arise; and the physician, 
however sagacious and prudent, is constantly exposed to seeing 
his most rational anticipations disappointed. 

It is evident that the principal sources from which the elements 
of prognosis may be derived, are, 1st, the disease itself; 2d, the 
peculiarities of the patient ; 3d, the external influences modifying 
both of the foregoing ; — for it must be admitted, that some affections 
are in their very nature more dangerous than others ; that some 
patients are remarkably susceptible of morbid impressions ; and 
that diseases vary according to climate, season, epidemic influence, 
&c* None of the circumstances relating to a case of disease are 
indifferent in forming a judgment respecting its probable course 
and issue; its causes, mode of invasion, symptoms, and duration ; 
its seat, nature, severity, complications, and its tractability under 
treatment, must all have their appropriate influence. 

The causes of disease are not, in general, of much value in prog- 
nosis ; yet they are, sometimes, of great importance in this con- 
nexion. Thus, inflammation of the peritoneum has a very differ- 
ent degree of gravity, according as it is idiopathic, or tubercular, 
or produced by perforation of the intestine, or some other abdomi- 
nal viscus, or occurs immediately after parturition. Tetanus of 
traumatic origin is infinitely more dangerous than when it arises 
from exposure to cold. A bubo proceeding from syphilitic infec- 
tion will suggest a very different prognosis from one caused by an 
excoriation of the heel. The rapidity or slowness of action of a 
cause, and the extent of surface upon which it acts, when it is of 
a chemical or mechanical nature, must also be taken into account. 
Poisons present an apt illustration of several of these points ; and 
privation of air by immersion in water or an irrespirable gas, or 
by strangulation, affords examples of the remainder. 

The mode in which an attack of sickness commences, is not 

* J. H. Bell, These de Concours, &c. 1838 ; M. M. Hardy and Behier. 






ELEMENTS OF PROGNOSIS. 203 

without significance, particularly during the prevalence of an epi- 
demic. The severity of the initial symptoms is then a pretty fair 
index of the subsequent gravity of the disorder. At other times 
the symptoms of invasion are of very uncertain value in prognosis. 
Many attacks of variola, of the mildest type, commence with as 
violent reaction as those of the confluent variety, and after two or 
three days of high fever, intense headache, and perhaps delirium, 
the eruption appears, and thenceforth the disease runs gently on 
towards cure. On the other hand, as was before remarked, many 
attacks of sickness are so mild at the commencement, as to excite 
no apprehension whatever, and yet daily grow worse and worse, 
until all hope of curing them is lost. The invasion of many is 
marked by severe paroxysms of nervous disorder, especially in 
women and children. In such subjects, this occurrence ought not 
to occasion particular alarm, unless followed by serious symptoms 
of another kind, such as coma and delirium. In old persons, on 
the contrary, every disease involves danger, no matter how mild 
its onset may be ; they can neither bear the debilitating effects of 
the disease, nor the treatment requisite for its removal when its 
symptoms grow alarming. 

Under the head of semeiology, the value of individual symptoms 
in prognosis will be duly set forth ; in this place some general con- 
siderations only will be presented. The elements of prognosis ad- 
mitted by the ancients, and confirmed in a great degree by the 
subsequent observation, not only of modern physicians, but of non- 
medical persons in habitual attendance on the sick, are drawn 
almost exclusively from the general symptoms. They consist of 
particular symptoms supposed in themselves to be of good or evil 
augury, and quite independent of the disease in which they occur. 
Such are extreme debility or emaciation, the Hippocratic counte- 
nance, great frequency or irregularity of the pulse, foetid exhala- 
tions from the skin, &c. Those which have been added by the 
researches of later times, are chiefly local, and discoverable by 
the several methods of physical exploration which have been de- 
scribed. By these means it is frequently possible to ascertain the 
existence of extensive organic disease, where the general symptoms 
give no indication of peculiar danger. This is singularly true of 



204 PROGNOSIS. 

diseases of the heart, of aneurisms of the aorta, and sometimes of 
pulmonary tubercles. The same methods often show whether a 
more or less dangerous lesion exists in a given case. For exam- 
ple, palpation enables us to distinguish between cancerous and 
other enlargements of the liver ; chemical tests applied to the urine 
indicate, under certain circumstances, whether renal disorder is 
attributable to Bright's disease, which is incurable, or to chronic 
inflammation, which may terminate in recovery. In a word, the 
prognosis in these cases depends wholly upon the accuracy of the 
diagnosis. If the latter be doubtful, the former will necessarily 
be uncertain ; but if the diagnosis be well established, the ultimate 
termination of the disease may confidently be predicted, for the 
diseases to which allusion has here been chiefly made, are all be- 
yond the power of medical art to cure, however much it may pro- 
long their course by palliative treatment. 

Certain maladies, amongst which may be mentioned eruptive fe- 
vers and acute inflammations, are, for the most part, regular in their 
course, the symptoms succeeding one another in an established 
order ; certain others, on the contrary, such as nervous affections 
and chronic disorders in general, are very irregular in the succes- 
sion of their morbid phenomena. Hence, any marked departure 
of the former from their accustomed course, must be interpreted as 
unfavourable to their cure. It usually indicates some serious but 
latent complication, which interrupts the natural progress of the 
attack. If the disease proceeds without amendment, beyond the 
period when it should begin to decline, or when, from the com- 
mencement, the graver symptoms assume an unwonted severity, 
there is reason to apprehend the worst. An opposite interpreta- 
tion, it is plain, should be given to the unusual duration of diseases 
in their nature incurable; in them, every day added to the disease 
is one gained by the patient. All sudden changes, whether for the 
better or worse, have a less important bearing upon the prognosis, 
than if they took place gradually, for they often last but a very 
short time. If the patient has, on former occasions, experienced 
the same disease as that for which he is under treatment, a know- 
ledge of any peculiarities it may then have presented, will aid ma- 
terially in forming an opinion in regard to its present course and 



THE NATURE AND SEAT OF THE DISEASE. 205 

probable issue, and of the importance of those peculiarities, should 
they again appear. 

Although, as a general rule, the longer a disease continues, the 
more unfavourable the prognosis, yet there are some exceptional 
cases, besides those already mentioned, of incurable affections. In 
certain acute disorders which are apt to be fatal within a limited 
period, their prolongation beyond that point is favourable. This 
has been shown by Mr. Farr to be true of epidemic cholera. He 
found that, after twelve hours, the proportion of cures to deaths 
was as 1*3 : 1 ; after twenty-four hours as 2 : 1 ; after two days 
as 3 : 1 ; and after three days as 4 : 1. In other words the longer 
the attack the greater hope was there of its cure. It is probable 
that this proposition holds in regard to all epidemic disorders. 

The nature of the disease must evidently have great weight in 
the formation of a prognosis. Neuroses, or functional nervous 
disorders, are essentially less dangerous than inflammatory dis- 
eases, and inflammation less so thanfcgangrene, or an organic af- 
fection. Specific diseases are, for the most part, more dangerous 
than analogous ones of the ordinary type. Hydrophobia is uni- 
formly fatal ; and syphilitic, more obstinate than simple eruptions 
of the skin, if the influence of treatment be left out of the question. 

The seat of a disease is of capital importance in prognosis. It 
is clear that the more essential to life is the organ attacked, the 
greater will be the danger. Affections of the brain, the heart, or 
the lungs, are infinitely graver than those of the liver, the spleen, 
or the limbs. So, too, the portions of a vital organ most essential 
to its functions are most apt to endanger life when diseased. Af- 
fections of the pons varolii, and of the crura cerebri, are more 
rapidly fatal than those of the hemispheres, because they are in 
more immediate connexion with the nerves by whose action life is 
maintained ; for a similar reason, lesions of the cervical portion of 
the spinal marrow involve greater danger than those of the inferior 
divisions. Valvular disease of the heart, and cancer of either ori- 
fice of the stomach, are more serious than corresponding alterations 
of other parts of these organs. Artificial anus, when its seat is in 
some portion of the large intestine, exerts but little injurious influ- 
ence upon the health, but if the same injury affect the superior 

18 



206 PROGNOSIS. 

portion of the alimentary canal, the food is discharged without be- 
ing thoroughly digested, the supply of nutritive matter is cut off, 
and rapid emaciation, and death by inanition soon follow, unless 
the endeavours to close the opening prove successful. 

It is unnecessary to insist upon the value in prognosis of the 
extent and intensity of diseases. It is evident that, other things 
being equal, the danger of a disease is in proportion to its mag- 
nitude, in physical extent, and in the development of its symp- 
toms. Yet there are often apparent exceptions to this plain pro- 
position. The concomitant circumstances may really be very dif- 
ferent in two apparently similar cases; and thus maybe explained 
the fatal termination of the one, and the recovery of the other, 
when the mere extent and intensity of the disease seemed to be the 
same in both. 

The complications of a. disease render its prognosis unfavourable. 
Thus, articular rheumatism, when simple, proceeds steadily towards 
cure, but when complicated |pith pleurisy, and more particularly 
with pericarditis, it is very apt to have a fatal termination, or to 
result in permanent unsoundness of the heart. Inflammation of 
the lungs or of the brain is of frequent occurrence in eruptive and 
other continued fevers, and uniformly aggravates the situation of 
the patient. 

Finally, the influence of treatment must be considered, in esti- 
mating the probable course and event of a case of disease. In 
those affections which experience has shown to be intractable to 
any form of treatment, the most unfavourable prognosis must of 
necessity be made. Yet even here it were unsafe to hazard an 
opinion entirely without qualification ; for it occasionally happens 
that well-marked cases of phthisis, cancer, ovarian dropsy, &c, 
undergo a spontaneous cure, or remain quiescent under the influ- 
ence of certain hygienic measures. If in a given case, and near 
its commencement, no treatment whatever has been employed, a 
rational hope of cure may be founded upon the proposed use of the 
means which have generally been found effectual in diseases of a 
like description. Much, however, will depend upon the real value 
of the ordinary treatment. If, as happens in a very large majority 
of instances, the treatment is settled only in general terms, but ad- 



THE CONDITION OF THE PATIENT. 207 

mits of, or requires, considerable modification in particular cases, 
the element of prognosis under notice is of little value ; for a slight 
change in the measures previously adopted may produce a decided 
amelioration of the symptoms; but if, on the other band, the treat- 
ment in question be definitely fixed, as, for example, cinchona in 
malignant intermittent fever, and yet has been tried unavailingly, 
the chances of the patient's recovery are extremely small. 

The circumstances of the patient constitute an important element 
of prognosis. Their action, as causes of disease, has already been 
considered ; from what was said of them in that connexion it will 
be readily understood that if capable of engendering or preventing, 
disease, they are also capable of aggravating or diminishing its 
severity. In this relation they often exert a paramount influence, 
and are therefore full of interest to the practitioner. 

The mere age of a patient must modify the prognosis based upon 
other considerations. Both extremes of life are exposed to peculiar 
dangers. Thus, it appears from the statistical tables of mortality 
in Sweden that more than one-fifth of all the children born, perish 
during the first year of their existence, and that of those who are 
living at the age of eighty, about the same proportion die in 
each year. It results, further, from extensive statistical tables, 
that nearly one-half of those born at a given time die before the age 
of puberty. Hence fh cases of disease occurring before this age, 
there is a stronger presumption against recovery than at any sub- 
sequent period of life, except the most advanced, and this presump- 
tion increases in strength in proportion as the patient is younger. 
As might be expected the exceptions to this rule, when they do 
occur, partake almost of the marvellous. They may well have 
given rise to the proverb that " while there is life there is hope;" 
they are examples of escape from death which no sagacity could 
anticipate, and which, it must be confessed, are usually accom- 
plished when medical art has expended all its resources in vain. 
The diseases of childhood are generally severe, and the more prone 
to a fatal issue from the fact that the subjects of them will not bear 
vigorous treatment. The inflammatory affections of the three great 
cavities then assume a more aggravated form than at any later 
period. Some affections which at other ages are of trifling consc- 



208 PROGNOSIS. 

quence are peculiarly dangerous in infancy. Coryza in a nursing 
child may prove fatal by suffocating it during its attempts to take 
nourishment, or the little patient may die of inanition from the im- 
possibility of swallowing and breathing at the same time. 

After the first dentition is complete, the diseases of childhood dimi- 
nish in severity. They, as well as other diseases, run their course 
at this period with singular rapidity, and are apt to be accompa- 
nied by nervous disorders, delirium, convulsions, and coma ; but 
these symptoms are not then by any means, of as fatal significance 
as in subsequent years, for they often arise in connexion with a 
very moderate degree of fever. Youth and adult life offer no pe- 
culiar prognostic signs. Energy and regularity are the general 
characters of their functions, whether normal or diseased. In the 
decline of life, as at its commencement, the predominant character 
of disease is feebleness ; but in the latter there is a constant ten- 
dency of the organism towards a more perfect development, a fund 
of vigour which often, as we have seen, withstands the exhausting 
attacks of disease, while in the former there is a constant tendency 
to decay, and but little recuperative power. In the maladies of old 
age, therefore, it is evident that the prognosis must commonly be 
unfavourable. They are, for the most part, obscure in their ori- 
gin, and often so insidious in their progress as scarcely to offer 
any external sign of their existence, until the destruction of the 
affected organ is far advanced. The treatment, too, which would 
have been appropriate to them at earlier epochs, then becomes in- 
applicable, and what would at one time have called for the anti- 
phlogistic method, may now obtain its only chance of cure, from 
the employment of tonics and stimulants. 

The sex, if the state of pregnancy and its consequences are left 
out of the question, has but little influence in the prognosis of dis- 
ease. It is true, however, that urinary calculus is a much less 
serious affection in the female than in the male, on account of the 
readiness with which calculi escape from the urethra of the former. 
Haemoptysis, which, in the male subject, is so uniformly a sign of 
commencing tuberculization of the lungs, is of very inferior im- 
portance in women, provided it coincide with derangement or sup- 
pression of the catamenia. Pregnancy has a marked influence 



THE CONDITION OF THE PATIENT. 209 

upon accompanying diseases, because either through their violence, 
or the means used to counteract them, miscarriage with all its 
dangers may result. Eruptive fevers, even of a mild type, in this 
manner become extremely perilous to the pregnant female ; they 
are very apt to be followed by the expulsion of the contents of the 
uterus, and in that case are nearly always fatal. On the other 
hand, it is commonly believed that pregnancy suspends the pro- 
gress of certain chronic diseases, and especially pulmonary con- 
sumption. But, as already pointed out, (page 122,) some of the 
most accurate observers have failed to find facts in confirmation of 
this opinion. Occasionally, also, pregnancy puts an end to mania 
and hysteria. 

Labour in certain cases of disease, or of morbid tendency, is a 
source of augmented danger. Such are aneurisms of the great 
vessels which may be ruptured; herniee of the bowels, which may 
become strangulated ; organic lesions of the uterus, which may 
induce its laceration ; and plethora, which may occasion apoplexy 
or convulsions, during the throes of parturition. 

The puerperal state stamps with peculiar gravity every af- 
fection which arises to complicate it. It greatly facilitates the 
injurious action of epidemic causes; it is subject to its own pe- 
culiar maladies ; including inflammation of the womb and its 
appendages, the peritoneum, and the cellular tissue of the pelvis ; 
it hastens to a promptly fatal issue all eruptive diseases, and ren- 
ders far more mischievous than usual, inflammation of the lungs 
or pleura, the pericardium, or the membranes of the brain. A 
knowledge of these facts should render the physician cautious in 
promising a rapid recovery, even after an easy labour, and vigi- 
lant to mark every change in his patient, and to detect every in- 
fringement of the directions he has laid down for her manage- 
ment. 

The hereditary tendency of a patient to the disease under which 
he labours, must nearly always render its prognosis unfavourable ; 
for it indicates a constitutional proclivity to such disease, which 
medical treatment can rarely arrest, although it may succeed in 
curing the individual attacks even of such hereditary diseases as 
proceed steadily to a fatal issue. The different forms of insanity, 

18* 



210 PROGNOSIS. 

epilepsy, and other nervous disorders, gout, and scrofula, rarely 
admit of a perfect cure under these circumstances. 

Much depends upon the strength of the patient at the period of 
his attack. That a feeble constitution, or the debility entailed by 
previous sickness, should exert an unfavourable influence, is self- 
evident, and is only alluded to in this place to enforce the propriety 
of making strict inquiries in regard to the patient's former health, 
in order that the physician may become possessed of all facts 
which can assist in maturing his judgment in regard to the case 
before him. 

The disposition of a patient, and his habitual cheerfulness or 
dejection, control to some extent, the issues of disease. Many bear 
pain with fortitude, become resigned to the prospect of a long con- 
finement, and the interruption of their ordinary pursuits, and are 
gay and hopeful in the midst of imminent perils. Others no sooner 
fall sick than they grow peevish, irritable, unreasonable, and im- 
patient of restraint ; they are disposed to brood over the evils of 
their situation, and to entertain the most gloomy apprehensions. 
It is apparent that the same disease must affect these two classes of 
persons very unequally; that it will, very probably, fail to exhaust 
the good spirits of the former, and will acquire additional gravity 
from the despondency of the latter. 

Habits and occupation are not without influence upon the cha- 
racter of diseases. It is a familiar fact, that drunkards are amongst 
the easiest victims of disease; they readily succumb under inju- 
ries and surgical operations, and during severe epidemics, very 
few of them escape alive. There are, indeed, exceptions to this 
rule ; cases in which intemperance seems to produce insensibility, 
and a power of passing unscathed through the severest trials of 
the constitution, resembling that of the lower animals. But in a 
large majority of instances, habitual indulgence in alcoholic drinks 
creates an inability either to resist disease, or to sustain medical 
treatment. All other debilitating causes have a like effect, such as 
prolonged abstinence, the exclusive use of vegetable food, over-fa- 
tigue, loss of sleep, immoderate study, venereal excesses, the indul- 
gence of any of the emotions, and particularly those of a gloomy 
character. 



THE CONDITION OF THE PATIENT. 211 

Amongst the external influences which modify the course of dis- 
ease, and consequently the opinion to be formed of its gravity, 
none is more efficient than the prevalent medical, or epidemic con- 
stitution. It sometimes imparts a singular gravity to the milder 
sort of affections, deprives the more dangerous ones of their accus- 
tomed severity, or causes some one organ to suffer in nearly every 
malady, and thus obliges the physician to form a prognosis differ- 
ent from that he would adopt under ordinary circumstances. In 
illustration of these points, it will be sufficient to mention the 
typhoid type, which, at times, every acute disease assumes; the 
very mild epidemics of the eruptive disorders which occasionally 
occur, and the tendency to cerebral, pulmonary, or intestinal in- 
flammation, which, now and then, seems to form, as it were, a 
parasitic attachment to all forms of disease. The prognosis in 
epidemic diseases varies according to their period ; at the com- 
mencement of the epidemic, it is not uncommon for nearly every 
person attacked to die ; the relative mortality begins to decline 
along with the positive mortality, and towards the conclusion of 
the epidemic, very few cases of it are fatal. 

The social condition of the sick has a large share in deter- 
mining the degree of their suffering, and the chances of their re- 
covery ; and this influence is not always in favour of those who 
are most amply provided with the comforts of life. This is strikingly 
shown by the results of the treatment of insanity. Occupation, 
and particularly manual labour, which is of more value in the 
management of this affection than all the other means combined, 
is generally so repugnant to those who have never been accus- 
tomed to toil with their hands, that they cannot be induced to pur- 
sue it, and hence they but too often remain unimproved, while their 
less delicate fellow-patients work out their salvation from the direst 
of all human calamities. The poorer classes, those which do not 
possess even the comforts of life, and at the same time furnish the 
greatest number of instances of vice, suffer most heavily from dis- 
ease. From these classes come the inmates of hospitals and alms- 
house infirmaries, who have long continued to be the principal 
models from which scientific writers have drawn their descriptions 
of disease. But the prognosis which is applicable to their diseases, 



212 PROGNOSIS. 

differs essentially from that of the same affections in private prac- 
tice, and amongst persons in less straitened circumstances. By 
nothing is this so clearly proven, as by the excess of mortality 
amongst the sick in public institutions, over that in private prac- 
tice, and especially as regards young persons and children. On 
the other hand, the poor, who at their own lodgings can neither 
command the best medical attendance, nor proper nursing, food, or 
medicine, have an infinitely greater chance of recovery by being 
removed to an hospital, where all these elements of a good treat- 
ment are bountifully provided. The improvement which those of 
them suffering under chronic disorders, experience by the mere 
residence in a well-conducted hospital, and before they are sub- 
jected to any medicinal treatment, attests the favourable influence 
of their change of circumstances. 

The preceding remarks must not be understood as in any de- 
gree disparaging the published labours of hospital physicians. 
Without them, medical science would scarcely exist. But their 
highest value is derived from the light which they throw upon the 
department of diagnosis. In prognosis and therapeutics, their re- 
sults must be modified by the study of disease in other classes of 
society distinguished by peculiarities arising out of their social po- 
sition and luxury, or their various pursuits, as agriculture, manu- 
factures, &c. 



PART III. 
SEMEIOLOGY. 

SYMPTOMS AND SIGNS DEFINED. VARIETIES OF SYMPTOMS. 
VALUE OF SEMEIOLOGY. 

Semeiology is that part of pathology which treats of the signs 
of disease. It differs from symptomatology, which treats only of 
symptoms in the abstract. The terms sign and symptom are very 
commonly, but erroneously, employed by medical writers as syno- 
nymous. This leads, as do most other inaccuracies of language, 
to a misconception of things, to confounding together an actual 
phenomenon, and an operation of the mind, and prevents a clear 
apprehension of the place which symptoms sliould occupy in the 
investigation of disease. Before entering, therefore, upon the de- 
partment of semeiology, it is proper that the meaning of the terms 
just mentioned, should be strictly defined. 

The phenomena of disease are symptoms. All that instructs us 
in regard to what is hidden or obscure in the past, present, or future 
state of a disease, is a sign. Signum est id quo cognito alterius 
ignoti notitiam inducit, is the definition of Galen. Hence, every 
symptom may become a sign, but every sign is not a symptom; 
thus the character of the cause may be a sign of the nature and 
probable course of the disease, but it is not, therefore, a symptom. 
A quarter-dollar may be described by enumerating its colour, spe- 
cific gravity, &c. ; these, its qualities, are to it, what symptoms 
are to a disease. But if the white colour and weight of the coin 
be employed to distinguish it from a half-eagle, which it resemble* 
in form and impression, and its value in cents is declared as indi- 
cating what it will buy, the colour, weight, and numerary value, 



214 SEMEIOLOGY. 

become so many signs ; diagnostic signs distinguishing the piece 
of money from another one, prognostic signs determining how 
much food or other commodity a tradesman will give in exchange 
for it. Symptoms, therefore, are converted into signs by the men- 
tal act of the observer. A patient may be more familiar with the 
symptoms of his complaint, than the physician ; yet his knowledge 
is useless, for he cannot convert them into signs ; he is unable to 
learn what they signify. This it is the physician's province to do, 
and this he must do, as a preliminary step to any rational judg- 
ment in regard to the nature of the disease, or the treatment which 
it calls for. 

Symptoms are of various kinds. An important division is into 
local and general; the former manifesting themselves in some 
particular locality, the latter in nearly every part of the economy 
at once. To these may be added sympathetic symptoms, which 
are indeed local, but developed at some point distant from that 
primitively affected, and dependent upon its disorder for their ex- 
istence. Thus in inflammation of the testicle, pain, redness, and 
swelling, are local symptoms, fever a general, and tumefaction of 
the parotid gland when it occurs, a sympathetic symptom. But, 
in strictness, there is no real difference between general and sym- 
pathetic symptoms', except that the former take place in systems 
which pervade the whole body, as the skin, the blood-vessels, &c, 
while the latter are evinced by organs of more limited extent. 
The connecting link between a local malady and its general symp- 
toms is quite as obscure, as that which gives rise to the sympa- 
thetic disorders peculiar to any disease. 

Premonitory symptoms are those which usher in a disease, and 
which indeed form part of it ; but, as several amongst them, such 
as chill, fever, debility, headache, &c, are common to the inva- 
sion of numerous maladies, they are usually spoken of as if they 
did not belong to the attack which is about to follow. 

A Pathognomonic symptom is one that is characteristic of a 
disease, and, although alone, indicates its nature, because it exists 
dn no other affection. Symptoms of this sort are very few indeed, 
and in every case, perhaps, consist in some physical accident or 
attendant of the malady. The discharge of worms is of course a 



SYMPTOMS AND SIGNS. 215 

certain sign of verminous disorder ; that of false membrane from 
the larynx, of croup: that of calculi from the bladder, of lithiasis; 
the detection of the acarus scabiei is conclusive of the itch ; &c. 
But there are, in each of several affections, a few symptoms which 
taken together may be regarded as characteristic, or so strongly 
indicative of a particular disorder as to leave but little room for 
doubt. An acquaintance with these is all-important in practice, 
since it at once leads the physician to a probable diagnosis, and 
directs him to the particular points upon which his subsequent ex- 
amination should chiefly bear. Thus if he find that there is cough, 
stitch in the side, rusty and tenacious sputa, and crepitant rhonchus, 
he can have but little doubt that the case is one of pneumonia ; or 
if he observes fever, precordial oppression, and a rubbing or to* 
and-fro sound over the heart, he may feel assured that he has be- 
fore him a case of pericarditis. Just in proportion to the minute- 
ness with which symptoms are studied, and the accuracy of the 
value assigned to them, will these characteristics of disease become 
more and more certain, and diagnosis be divested of its difficulties. 
It is customary to speak of functional phenomena only as symp- 
toms, and of those revealed by physical exploration as signs, as if 
the latter were par excellence significant. Besides being, as already- 
shown, an abuse of language, such a phraseology is founded on a 
purely arbitrary division. For it surely constitutes no essential dif- 
ference between two phenomena, that one is perceived by the sense 
of hearing and the other by that of sight. A pulmonary rhon- 
chus is appreciated by the senses neither more nor less than pale- 
ness or emaciation. No one denies that the character of the pulse 
is a symptom, yet this is quite as much a physical phenomenon as 
the dulness of the chest in pleurisy ; and it is perceived by the 
very same sense, that of touch, which measures the size, and esti- 
mates the consistence of an abdominal tumour. The only differ- 
ence is that the last two phenomena are supposed to require a more 
careful, prolonged, and difficult examination than the first. 

In the ensuing chapters the symptoms furnished by each of the 
systems of the body will be studied ; not by an enumeration of them 
merely, but also by a review of their relations to diagnosis and prog- 
nosis. Semeiology is thus shown to be the key to the language of 



216 SEMEIOLOGY. 

symptoms; to be the interpreter of disease. When once well learned, 
the history of particular diseases seems like illustrations of settled 
principles, and is divested of most of the difficulties and apparent 
contradictions which so often, and with such good reason, discou- 
rage the student when he first reads a treatise, or hears a course 
of lectures on " the Practice of Medicine." He is then as apt to 
be bewildered as one who should study chemistry without prelimi- 
nary notions about heat, light, electricity, and affinity; the de- 
scriptions of action, reaction, and combination which fill his text- 
book, would seem to him little better than a barbarous jargon. 
The elements of disease, the individual symptoms, must be 
presented to the student's mind in their simplicity, before he can 
comprehend them in their natural combinations. By dissecting a 
disease, as it were, by considering its symptoms separately, and 
comparing each of them with analogous ones in other affections, 
he arrives at what is essential to constitute each symptom, to ex- 
amine it as disentangled from those which ordinarily accompany 
it, and hence to form a correct notion of its importance under 
whatever circumstances it may afterwards be observed. 



CHAPTER I. 

SIGNS FROM THE EXTERIOR OF THE BODY, 

Although, for the present purpose it matters little what part of 
the body is first examined, in relation to the diagnostic and prog- 
nostic signs furnished by it in disease, yet it seems most natural, 
and it accords with the best usage, to consider first that which first 
presents itself to the observation of the physician, in the body taken 
as a whole ; then to examine, in due succession, its cutaneous sur- 
face, the several portions of this latter which are especially con- 
nected with internal organs, and the several systems which are 
charged with distinct functions. 

The condition of the exterior of the body is very intimately con- 
nected with that of the vital organs, and presents many points from 
which their degree of energy may be inferred. The posture assumed 
by the patient, the development of the whole frame, the colour, tempe- 
rature, and secretions of the skin, the muscular strength, are, all of 
them, circumstances which it is important to observe. Some ono 
of these, or several of them united, frequently communicate to the 
physiognomy of the patient an expression which reveals to a prac- 
tised eye the nature of his disease. Indeed they have to such an 
observer a significance far beyond what he is able to explain by 
their analysis, just as those most expert in reading a man's cha- 
racter in his face, are often the least capable of describing the form 
or feature which is indicative of a particular passion or propensity.. 



19 



218 SEMEIOLOGY. 



SECTION I. 

THE POSITION AND SIZE OF THE BODY. COLOUR, TEMPERATURE, 

ETC., OF THE SURFACE. 

A patient's attitude presents some valuable indications, whether 
he stands, or sits, or lies down. In the erect position, if one shoul- 
der is higher than the other, it may arise from lateral curvature of 
the spine, from contraction of the lower side of the chest after 
pleurisy, from dislocation of the shoulder joint, or be owing merely 
to the habit of writing in a sitting posture. If the body is thrown 
very much backward, it may depend upon the feeling of insecurity 
which attends commencing paraplegia. The greater or less vigour 
of the movements of one side of the body in walking, the dragging 
of the foot, or loose swinging of the arm, are observed in partial 
hemiplegia. Irregular and rapid twitching of the limbs and trunk 
in different directions are characteristic oT chorea ; more violent 
movements of the muscles belong to the several forms of convul- 
sion ; that condition in which a limb retains any position which is 
given to it indicates catalepsy ; and the rigid contraction of the 
muscles upon the anterior or posterior part of the trunk, bending 
it in the form of an arch, is a symptom peculiar to tetanus. 

In most diseases the ability to maintain the erect position is of 
good augury, provided the patient has not, immediately before, 
been confined to bed, or that he has regained this power after 
regular convalescence. But when the disease itself forces the 
patient to stand, or sit up, it is a very unfavourable sign. This 
occurs in most of the affections of the thoracic and abdominal 
cavity in which the function of respiration is directly or indirectly 
impaired, for in any other position the patient cannot so readily 
breathe. Yet, as a general rule, the relief afforded by it in organic 
disease, is only partial and temporary, besides which it exposes to 
sudden death by syncope. This danger is, however, much more im- 
minent in diseases attended with great debility; in these the desire of 



DECUBITUS. 219 

the patient to stand or sit indicates mental aberration. The hazard 
is still greater if the individual is at the same time distinctly delirious. 
The immediate cause of death in many cases of phthisis, dysentery, 
uterine hemorrhage, typhus fever, &c, is syncope, induced by sit- 
ting up to obey the calls of nature, or for the sake of change. 

Decubitus is the position assumed by a patient while lying 
down. It affords numerous and valuable signs. A healthy per- 
son in bed usually lies upon the right or left side, with the limbs 
semi-flexed, the head bent somewhat forward, and the whole body 
in an unconstrained and easy posture. The nearer the position of 
a sick person corresponds to this, the less grave, in general, is his 
disease. In most affections there is some departure from this mode 
of lying ; but since there are individuals who, even when per- 
fectly well, take a very different posture from that just described 
as the ordinary one, their habitual position should be learned before 
any inference is drawn from the peculiarity of their decubitus in 
sickness. 

The supine position, or dorsal decubitus, is that which belongs 
to nearly every disease of debility ; it is the one which gives the 
greatest support to all the limbs, and leaves the freest play to the 
lungs and heart, and is therefore instinctively assumed when ex- 
haustion is extreme. It is also, however, met with when the pain 
attending motion is so intense as to force the patient to remain 
perfectly still, as in acute peritonitis, and in general articular 
rheumatism. Its different degrees indicate those of exhaustion. 
The patient may simply lie motionless without the power of turn- 
ing upon his side, or he may have his knees drawn up, or, in spite 
of all the efforts of the attendants, he will slide down towards the 
foot of the bed ; or his arms may be thrown to a distance from the 
body, and the lower limbs widely stretched apart; if he lies thus 
and still slips downwards in bed, with the head thrown far back- 
wards, the neck prominent, or the chin resting upon the chest, it 
may be concluded that he has not long to live. Some of these 
symptoms, as will readily be understood, may occur in paraplegia, 
without bearing so unfavourable an interpretation ; the condition 
of the lower extremities disposes the patient to lie upon his back, 



220 3 E ME 10 LOGY. 

and prevents him from resisting the force of gravity which carries 
his trunk downwards. 

It is unusual for a sick person to lie prone, or on the abdomen, 
and it either indicates that he is suffering from an attack of those 
colicky or cramp-like pains in the belly, in which pressure affords 
relief; or that he is hemiplegic and has accidentally turned upon 
his face, and is unable to resume his previous posture ; or, finally, 
that he is threatened with delirium. 

Lying upon the side, or upon one rather than the other, has no 
importance in prognosis, but is regarded by many authorities as 
having a real value in the diagnosis of diseases of the chest. 
Some, however, have maintained that the patient prefers lying on 
the affected, and others on the sound side, when one lung or pleura 
is alone diseased ; while others believe that the sign in question 
is of no value whatever. It must indeed be admitted that its value 
is not constant ; nevertheless, there is a true relation between the 
lateral decubitus and the side of the chest affected. In the forming 
stage of pneumonia and pleurisy, when the stitch in the side is felt, 
this part is usually sore if handled or percussed, and the suffering 
is increased when it is pressed beneath the weight of the patient's 
body. So long as this pain lasts, he avoids aggravating it, and 
lies upon the opposite side. After a day or two, the severity of 
the pain gives way to dyspnoea ; as the hepatization of the lung 
proceeds, or the pleura! cavity is distended with serum, the patient 
instinctively takes the best means in his power of giving a large 
expansion to the healthy lung by lying upon his back, or upon the 
affected side. Hence, it may be received as pretty generally true, 
that the patient lies upon the sound side only when it gives him 
pain to lie upon the other. Such at least is the case as regards 
thoracic affections ; in hemiplegia, on the contrary, there is a con- 
stant tendency to turn upon the weaker side, which, as already 
pointed out, may become a source of danger. When both cavities 
of the chest are diseased, the dorsal decubitus is nearly always 
preferred. 

The sitting position has already been mentioned as the one gene- 
rally assumed in cases of great difficulty of breathing, attended 
with structural or infiammatorv disease of the lungs, heart, or ab- 



DECUBITUS. 221 

domen. The recumbent position growing intolerable as the disease 
advances, the patient first has his head raised by pillows, and then 
gradually assumes a more and more erect posture, until he sits up- 
right, or upon the side of the bed, grasping his knees, the back of 
a chair, or some other article, by which means the shoulders be- 
come fixed points, and the respiratory muscles attached to the 
upper extremities, act most favourably in expanding the chest. 
This posture is assumed in orthopncea, from whatever cause it may 
arise. When the trachea is the seat of a physical obstruction, as 
in membranous croup, the patient not only sits up and grasps some 
steady object, to aid the action of the respiratory muscles, but usu- 
ally stretches out the throat by throwing the chin upwards, and 
the head backwards. 

In most cases of extensive palsy, and of that dulness of intellect 
which is apt to accompany softening and tumours of the brain, and 
the commencement of dementia, the patient often obstinately main- 
tains the same position, and if disturbed, will soon relapse into it. 
There are other diseases, however, which are marked in some 
part of their course with great agitation and restlessness. The 
patient tosses about in bed, or is perpetually rising up or lying 
down, or will not be persuaded to remain in bed, all of which 
shows either the presence or imminence of a severe febrile attack. 
It is a state of things which very commonly precedes the appear- 
ance of the eruption in the exanthematous fevers. In this con- 
nexion it is of subordinate consequence, for it does not form an 
index of the subsequent gravity of the attack ; but when it arises 
in the course of an acute or chronic disorder, it must be viewed 
with alarm, for it usually announces some serious complication, or 
marked aggravation of the original disease. Tremor, which is a 
sort of subdued agitation, is* the usual concomitant of low typhus 
fever; it is also one of the prominent symptoms of a disease, to 
which, indeed, it has given a name, delirium tremens ; and of an 
affection peculiar to old persons, and one whose organic causes are 
not well understood, to wit, paralysis, agitans t — the shaking- 
palsy. 

Size or volume. — These qualities of the body demand conside- 
ration in connexion with the present subject, for its increase or 

19* 



222 SEMEIOLOGY. 

diminution in size is produced by nearly every disease. The 
former is due to one of four causes; an accumulation of fat, or 
obesity ; an afflux of blood or other liquids to certain parts ; the 
effusion of serum in serous cavities or cellular tissue, constituting 
the several forms of dropsy ; and the introduction of air into, or 
its generation within the body. 

A moderate development of adipose matter is indicative of health, 
but that excess of it which is known by the name of obesity, or 
polysarcia, is in reality a disease. It is a condition most frequently 
observed in middle life, and amongst the indolent and luxurious of 
both sexes, but especially of females. In the latter it is very apt 
to come on after child-bearing has ceased, and in males who have 
relinquished the active and anxious pursuits of commerce and 
trade, for the serene occupations of the bon-vivarit; but men 
engaged in laborious and active employments rarely grow fat. 
In obesity, the adipose matter is not always equally distributed 
over the body, but is more apt to be inordinately developed in the 
walls of the abdomen, and the great omentum, than elsewhere. It 
has been known to reach a thickness of fourteen inches in this 
situation. 

Corpulent persons offer very little resistance to the attacks of 
disease. No sooner are they laid on a bed of sickness, than their 
fat seems to lie like a vast incubus upon them, oppressing their 
breathing, preventing a change of position, and rendering the parts 
in contact with the bed very liable to inflammation and gangrene. 
Such persons, too, are usually of feeble constitution ; their muscles 
becoming atrophied while the weight of their body increases, they 
grow more and more unable to take exercise, and readily sink 
under disease. In general, too, they are short-lived, as well from 
the direct influence of their obesity, as from the affections to which 
it gives rise. Such are congestion of the brain, apoplexy, and 
gout ; attenuation, softening and rupture of the heart, and syncope 
from the feebleness of the cardiac muscles, which are replaced by 
large masses of fat, all of which conditions may become causes of 
sudden death. It is not uncommon after acute diseases, typhoid 
fever for instance, for an individual to grow fat, and this, if it ac- 
company a good appetite, and a sense of general well-being, 



VOLUME OF THE BODY. 223 

indicates a beneficial change in the character of the constitution. 
In the gloomy forms of insanity, which are, like the depressing 
passions generally, attended with loss of flesh, increase of size is a 
most favourable sign, provided that at the same time the mental 
condition improves ; but there is no more conclusive indication of 
the incurability of insanity than improvement in flesh, while the 
mental disorder continues unabated. 

A general augmentation of the bulk of the body from the abnor- 
mal distribution of its fluids, is, of course, impossible. The real or 
apparent fulness which exists during the first stage of febrile affec- 
tions, and especially of the exanthemata, is in all probability owing 
to the suspension of the excretions from the skin and bowels ; it 
is nearly always accompanied with redness and heat of skin. 
Local tumefaction from th« cause in question, may depend upon 
the presence in the vessels of a part of more blood than natural, as 
is seen in erythematous and erysipelatous inflammations; or upon 
an effusion or deposit of serum' or other substance, in the cellular pa- 
renchyma, or in some membranous cavity. In the large serous effu- 
sions constituting dropsies, the iocal tumefaction is always attended 
with general loss of flesh, as is well shown when the fluid con- 
tained in a dropsical abdomen is removed by tapping. General 
dropsy of the cellular tissue is called anasarca ; the same affection 
when local, cedema ; and serous effusions into different cavities, 
have received appropriate names, as hydrothorax, water in the 
chest; hydrocele, dropsy of the tunica vaginalis testis ; hydrar- 
throsis, dropsy of a joint ; &e. Some of these forms of tumefaction 
are very important in diagnosis. (Edema about the ankles may 
arise from any cause of general debility, such as chlorosis, conva- 
lescence from acute disorders, or simply remaining for a longtime 
in the erect posture ; but, aside from these connexions, it is one of 
the first evil signs of valvular disease of the heart. (Edema of the 
eyelids and face, which may also proceed from the same debili- 
tating causes, is, in their absence, a strong indication of Bright's 
disease of the kidney. Ascites may form as a part of general 
dropsy, but when it occurs primarily, it is nearly always due to 
structural changes in the liver or spleen. Hydrothorax and hy- 
dropericardium, (not pleurisy and pericarditis,) are Usually inci- 



224 SEMEIOLOGY. 

dents of general dropsy. Hydrocephalus, ovarian dropsy, hydro- 
cele, and oedema limited to a part of one side of the body, are 
nearly always owing to strictly local causes, the last, generally, 
to obstruction of a venous trunk leading from the swollen part. 

Local or general enlargement of the body may arise from em- 
physemci) or a puffiness of the skin from air confined in the cellu- 
lar tissue beneath it. When genera!, it almost always proceeds 
from penetrating wounds of the chest. The rising and falling 
movement of the ribs acts like that of a pump, and forces air into 
the cellular tissue upon the edges of the wound, whence it is dis- 
seminated over the whole body, and to such a degree, sometimes, 
that the skin becomes as tight as a drumhead, and may render in- 
cisions in various parts necessary, to give exit to the air. The 
distended integuments do not, as in anasarca, pit upon pressure, but 
feel elastic under the finger, and give the sensation, and sometimes 
the sound, of crepitation. Local emphysema is observed in the 
neighbourhood of gangrenous wounds. It is often met with in dis- 
sections, but is then usually the result of decomposition after death. 
Air is occasionally generated or liberated in the cavity of the 
pleura, independently of any connexion between it and the lung 
or the surface of the body, forming a rare variety of pneumo- 
thorax. Very frequently it distends the abdomen, by collecting 
within the intestinal canal. This condition is known as tympani- 
tes. It is an ordinary incident of hysteria, and in that case is un- 
attended with danger. But when it arises in consequence of in- 
flammation of the peritoneum, it portends a disastrous result. It 
is said, also, to be capable of destroying life when it takes place in 
a female recently delivered, and exhausted by loss of blood, through 
the impediment it creates to the descent of the diaphragm, and the 
dyspnoea and syncope which thence result. 

Cellular emphysema, even when general, is not commonly at- 
tended with serious results. The affection is very annoying while 
it lasts, but is of short duration, for the effused air is gradually re- 
moved by absorption. Cases are, however, recorded by Larrey, 
and P. Frank, in which the swelling of subcutaneous emphysema 
was so great as to produce asphyxia and apoplexy, by compressing 
the air-tubgs and jugular veins. General anasarca is rarely dan- 



EMACIATION. 225 

gerous, unless it depends upon organic disease ; in that case, it, as 
well as all other forms of dropsy of similar origin, are with diffi- 
culty, if at all, curable* 

Loss of flesh is, perhaps, the most unfailing of all the symptoms 
of disease, and varies so much in degree, and the circumstances 
under which it occurs, as to constitute a valuable sign. It may 
depend upon some general cause affecting nutrition, such as sor- 
row and anxiety, loss of rest, over-fatigue, insufficient food, pro- 
longed lactation, habitual excesses in the use of alcoholic drinks, 
old age, &c, — causes which are not properly diseases. When 
progressive emaciation is observed without any apparent physical 
cause, these influences ought to be taken into consideration. 

In acute diseases, unless accompanied with profuse discharges, 
there is little or no emaciation during the active stage ; but in such 
affections as cholera morbus, a few hours may suffice to reduce 
the size of the body to a wonderful extent. In other acute disor- 
ders, the subsidence of fever corresponds to the commencement of 
emaciation, which proceeds from day to day, until convalescence 
has fairly set in, and nutritious food may be taken, without the 
risk of renewing febrile reaction. Such temporary emaciation is 
to be regarded as a favourable sign, in so far as it indicates the de- 
cline of disease ; but if, instead of being temporary, the loss is con- 
stant and progressive, and that in spite of the most nutritive and 
even stimulating diet, there is good reason to suspect the existence 
of some latent organic disease, such as tubercles, whose develop- 
ment has been hastened by the accidental acute disorder. Many 
cases of fatal consumption may thus be dated from the occurrence 
of pneumonia, pleurisy, or typhoid fever; not that these diseases 
have any especial tendency to generate tubercles in the lungs, but 
that they so weaken these organs as to prevent their resisting any 
longer the hereditary or acquired proclivity to tubercular disease. 

When acute diseases are prolonged greatly beyond their ordi- 
nary term, emaciation ceases to be a propitious sign. Jts progress 
indicates the gradual exhaustion of the powers of life, the imper- 
fection of the assimilative function, and the supervention of a de- 
gree of debility which mere medicine is powerless to remove. 
Such cases usually owe their cure to change of air or diet, a visit 



226 SEZVIEIOLOG Y. 

to the sea-shore, to the mineral springs, &c. The most striking 
examples of emaciation cured by such means, are presented by 
children with enteritis, (summer complaint,) and, more rarely, by 
adults labouring under chronic intestinal fluxes. Every one accus- 
tomed to see infantile diseases in this country, must have met with 
many instances of children in the last stage of emaciation, (maras- 
mus,) and looking almost too feeble either to swallow or cry, who 
have begun to revive, immediately on being removed from the 
city, and in a few weeks gained a ruddy complexion, and plump, 
firm flesh. 

But it is in chronic diseases of a slow and insidious nature, that 
emaciation is most considerable, and of most evil augury. Tt is 
often, for a long time, the only sign of pulmonary tubercles, and 
may even be well marked before the deposit of these bodies can be 
detected by the aid of auscultation and percussion. This is pe- 
culiarly true of the cases in which the tubercles are not, as more 
commonly happens, confined to the summit of the lung at the com- 
mencement, but are disseminated throughout the whole extent of 
both lungs. In them the occurrence of haemoptysis with progres- 
sive emaciation, is quite sufficient to determine the character of the 
disease, and foreshadow its fatal issue. Cancer does not, in gene- 
ral, exert so marked an influence upon nutrition, until it reaches 
the stage of softening, unless it be so situated as to form a mecha- 
nical impediment to the performance of an important function. 
This is what takes place when a cancerous deposit is formed 
around either the cardiac or the pyloric orifice of the stomach, 
causing the rejection by regurgitation or vomiting, of a large part 
of the food, and, as a consequence, rapid and extreme emaciation. 

The great loss of flesh which occurs in several affections is 
usually attributed to the profuse discharges which attend them ; 
thus in pulmonary phthisis the loss by sweating and diarrhoea is 
very considerable ; in uterine cancer by hemorrhage and sup- 
puration ; in diabetes by a discharge of urine, &c. ; but this expla- 
nation is not applicable to all cases. Fever, without any remark- 
able loss by excretion, is always followed by emaciation, but its 
mode of action is not well understood. In chronic diseases the 
supervention of fe\ar, without inflammatory complication, generally 



COLOUR OF THE SKIN. 227 

indicates that the attack is about to commence its downward 
course. 

The colour of the skin depends partly upon the race, age, tempera- 
ment, and degree of exposure to light and heat, and partly upon 
the state of health of the individual. The latter concerns us chiefly 
at present. Paleness of the skin may arise from whatever causes 
repel the blood from the surface of the body ; or so diminish its 
amount as to leave the superficial capillaries unfilled; or alter its 
composition, by diminishing its proportion of red globules, or in- 
creasing that of water. Hence cold baths or damp cold air, de- 
pressing mental emotions ; hemorrhage, vomiting and purging ; 
chlorosis, scurvy, Bright's disease, &c. ; render the skin pale. 
Long confinement in badly-lighted rooms, even without positive 
disease, has a similar effect. 

Paleness occurring at the commencement of the decline of acute 
diseases, is, like emaciation, a normal occurrence, and therefore a 
favourable sign ; but when it takes place suddenly at an earlier 
stage, particularly if the skin has just before been red, it is of evil 
augury. In chlorosis and anemia there is not a pure paleness of 
the skin, but a hue like that of imperfectly bleached wax, or a light 
straw-colour with a shade of green. In cancerous affections this 
hue is modified by a slight admixture of lead-colour, forming an 
olive or earthy complexion which is very characteristic. A livid 
hue approaching to blackness is observed in parts about to become 
gangrenous, and especially in dry gangrene, which sometimes af- 
fects a whole limb at once. A less intense colour, a bluish, or as 
it is called, cyanotic hue, is frequently met with in new-born infants 
and others in a state of asphyxia, when any obstacle to hrematosis 
exists in the lungs, causing a stagnation of blood in these organs j 
in severe attacks of cholera ; and, above all, in the disease whose 
principal symptom is blueness of the skin, and which is hence 
called cyanosis. In all of these examples, the cutaneous disco- 
loration is due entirely to congestion of the venous capillaries, in 
consequence of some obstacle to the return of the blood to the heart. 
This explanation of the phenomena of cyanosis is not that which 
has generally been accepted. It has for a long time been taught 
that in all cases of congenital cyanosis, the foramen ovale of the 



228 SEMEIOLOGY. 

heart remains open, and permits the dark venous blood of the right 
side of the heart to mingle with the bright arterial blood of the left 
side. This admixture, it has been alleged, forms a dark-coloured 
fluid which communicates to the skin a cyanotic hue. Louis was 
the first person of recent times to call this doctrine in question ; 
and, as early as 1826, he showed that a communication between 
the two sides of the heart might exist without the concurrence of 
cyanosis, and that on the other hand this colour might arise with- 
out any malformation or disease of the heart whatever. He further 
stated the conclusion that many cases of the affection were owing 
to congestion, produced by an obstacle to the venous circulation. 
These views were more or less fully adopted by several distin- 
guished medical men in France; but the doctrine previously taught 
continued to prevail. In 1843 Dr. Moreton Stille,in his inaugural 
thesis, proved by the analysis of a large series of cases, that the 
cause of cyanosis was uniformly either contraction, obstruction, or 
imperforalion of the pulmonary artery, or else some physical im- 
pediment to the natural course of the blood possessing a similar 
mode of action, such as concentric hypertrophy of the right-ven- 
tricle, singleness of the heart with contraction of the auriculo-ven- 
tricular opening, &c. This conclusion has since received ample 
confirmation, and especially from the investigations of Dr. Norman 
Cheevers of London. 

It is remarkable that the explanation given by Morgagni of a 
case of cyanosis witnessed by him, and which tallies precisely with 
the results of the laborious analyses above alluded to, should have, 
for so long a time, failed to convince pathologists of their error in 
attributing to admixture of arterial and venous blood the phenomena 
of cyanosis. Morgagni, after describing the case, and the dissec- 
tion which he made upon the patient's death, disclosing a contracted 
and ossified pulmonary artery, declares this lesion to have been 
the cause of the symptoms ; for, he remarks, " the contraction of 
the pulmonary artery allowed a very diminished quantity of blood 
to pass through it and the corresponding vein to the left side of the 
heart, so that less blood than natural was circulated through the 
body ; and on the other hand, it caused the blood to accumulate 
and stagnate in the right ventricle, then in the right auricle, and 



COLOUR OF THE SKIN. 229 

finally in all the veins, whence resulted the discoloration of the 
skin, the dilatation of the right cavities, and the opening of the 
foramen ovale whose valve was pressed by more blood upon the 
right than upon the left side." The confirmation of this ingenious 
statement by the result of an analysis of all the cases of cyanosis 
that could be collected, is a beautiful illustration of the uniformity 
of nature's laws, and a proof of the rare sagacity of the great 
founder of the pathological school. 

Nitrate of silver, when administered internally, is very apt to 
produce an indelible slate-colour of the skin, and even of the viscera, 
in persons long subjected to its use. Not many years ago this 
agent was much employed in the treatment of epilepsy, but unfor- 
tunately its influence was much more distinctly marked upon the 
patients than upon their disease. This discoloration is of course 
readily distinguished from all others by its peculiar shade, as well 
as by a knowledge of its cause. 

Redness of the skin is never general, except in some acute 
eruptions, such as scarlatina, measles, and small-pox ; in the 
greater number of diseases it is either limited to the face, and is 
marked only during the early stage, as in fevers of an active type, 
and inflammations of internal organs, or is local in a more restricted 
sense, being confined to portions of the surface upon or near which 
the inflammatory process is going on. Thus it attends inflamma- 
tion of the skin, whether this results from direct injury, or arises 
from some constitutional cause. There may, however, be a red- 
ness which is not inflammatory, but due to the extravasation of 
blood into the cutaneous tissue, as in low forms of fever; or to 
congenital dilatation of the capillary veins, as in ncevus materniis ; 
or simply to some temporary impediment to the circulation through 
a part, as where a limb is tightly encircled with a band. In the 
former class of cases, the colour is bright or almost scarlet, but in 
the latter it approaches more nearly to the hue of venous blood. 
When the livelier colour suddenly disappears, leaving the skin 
pale, or is exchanged for the darker shade, the prognosis becomes 
highly unfavourable. This is strikingly true of the colour of the 
skin in exanthematous fevers. 

Jaundice, or yellowness, is another important alteration of 

20 



230 SEMEIOLOGY. 

colour. It is of various shades between bright lemon and dark 
olive, depending a good deal upon the natural complexion of the 
individual ; it is lighter in the young and fair, and darker in the 
old and tawny, The icteric tinge is not only seen upon the sur- 
face of the body, in the skin and conjunctiva, but also in the serum 
of the blood, in the urine, sweat, and the excretions generally, and 
in nearly all the tissues of the body. Yet it is remarkable, that 
the mucous membrane, with its secretion, and the saliva, are 
scarcely ever stained of this colour. This difference may, perhaps, 
be accounted for by the fact, that the skin and kidneys are excre- 
tory organs, whose principal office it is to separate from the blood, 
substances which are unfit for the purposes of nutrition, while the 
mucous membranes and the salivary glands are destined princi- 
pally to form new compounds, which have important purposes to 
subserve in the economy. The bile pigment, therefore, circulating 
in the blood, where it does not naturally belong, at least in any 
notable quantity, is more likely to be eliminated with the sweat 
and urine, than with any of the true secretions. 

A notion formerly prevailed, that every object appears yellow 
to jaundiced persons, and the idea has been incorporated into poeti- 
cal and popular language. It is not, however, correct. The dis- 
order of vision in question, exists only in a small proportion of 
cases of jaundice, and is caused by yellowness of the vitreous hu- 
mour and cornea. 

The immediate cause of yellowness in jaundice is the deposit of 
the colouring matter of the bile in the skin, and other tissues and 
fluids. This substance must be presumed to exist in the blood of 
jaundiced persons, and has indeed been found there, by the greater 
number of competent chemical analysts ; but it ought not to be 
concealed, that some even of the most distinguished, have declared 
themselves unable to detect its presence. Others claim even to 
have demonstrated it in healthy blood ; and it cannot be denied, 
that without the admission of this claim, its existence in icteric 
blood must be accounted a mystery. The prevalent belief is, that 
the bile pigment is absorbed, after having been secreted by the 
liver, an opinion founded upon the most ordinary cause of jaun- 
dice, the obstruction of the ductus communis, or one of the branches 



JAUNDICE. 231 

of (he hepatic duct, by a gall-stone, by the pressure of a tumour, 
&c. But amongst the cases of most intense jaundice, are those of 
an acute kind, attended with comatose symptoms, in which it is 
alleged that the secernent cells of the liver are wanting, and in 
which, therefore, no biliary secretion can take place. Jaundice, 
in these cases, does not seem explicable upon the same principle as 
in the former, and in order to obtain an explanation at all satisfac- 
tory, and which will apply to all cases, there seems to be no other 
alternative than to admit that the colouring matter of the bile, and 
it may be, other constituents of this fluid, exist originally in the 
blood, and there accumulate, whenever the liver becomes gorged 
with bile, in consequence of the closure of its outlets, or of the de- 
struction of its secernent cells. Yet this mode of accounting for 
jaundice does not remove all difficulties ; it does not explain how 
the symptoms should be so different between suppression and re- 
tention of the bile, and obliges us to look further into the states of 
the system accompanying these two conditions. From such an 
examination, it will probably appear that the difference in gravity 
of the two affections depends, not on the presence of more or less of 
the elements of bile in the blood, but, in the one case, in suppres- 
sion of bile, upon a radical alteration of the latter fluid, a poisoning, 
as it has been called ; and in the other, upon the nature of the af- 
fection, whether inflammatory, mechanical, or malignant, which 
produces the retention. 

However these things may be, jaundice, as a symptom, is valua- 
ble in diagnosis. It is a phenomenon of several fevers prevalent 
in tropical and adjacent regions, the remittent, bilious, and yellow 
fevers; but it is chiefly useful, by the mode of its accession, in 
distinguishing from one another, several affections which interest 
the liver. When it comes on with indigestion, slight fever, slug- 
gishness, and uneasiness in the right hypochondrium, and after a 
week or two disappears under the influence of diet and purging, it 
must be regarded as depending on a disorder, which, if not abso- 
lutely functional, is, at least, not purely inflammatory. When it 
follows violent and spasmodic pain in the region of the liver, it is 
attributable to the arrest of a gall-stone in the biliary passages; 
when it precedes delirium and coma, or convulsions, it indicates 



232 SEMEIOLOGY. 

disorganization of the hepatic cells ; when it comes on slowly, 
lasts a long time, and acquires a very dark tinge, it commonly de- 
pends upon some organic disease of the liver, or the adjacent or- 
gans, capable of obstructing the discharge of bile from the ducts ; 
and finally, when it succeeds a fit of violent passion, it is neither 
attended nor followed by any other symptoms. 

From this sketch, it is plain that jaundice is of but little conse- 
quence in prognosis, since the symptoms with which it is asso- 
ciated declare much more positively than itself, the gravity of the 
affection in which it occurs. Alone, it involves no danger ; it is 
often found in persons who, apart from their yellowness, appear to 
be in perfect health. Examples, even, are known of children who 
were jaundiced, and yet thrived well, and in whom, after death 
from some accidental affection, the gall-ducts were found impervi- 
ous, or even entirely absent. 

Allusion has already been made to the red spots which appear 
upon the skin, in consequence of dissolution of the blood. These 
may be comprised under the general title of purpura, which in- 
cludes the eruptions without fever, and the petechia, which accom- 
pany certain febrile diseases. In the non-febrile disorder, the spots 
may vary in size, from a line to an inch in diameter, and are al- 
ways below the surface of the skin ; but in petechial fevers, the 
eruption consists of small points resembling flea-bites, (petechia,) 
except that they have not around them a light-red disk, but like 
these latter, they project slightly above the surface. Neither form, 
however, disappears under the pressure of the finger. The shoul- 
ders, and other parts where a fold of the skin has been pinched by 
the weight of the patient, often present a line of minute extravasa- 
tions, looking precisely as if caused by a blow with a whip-lash, 
whence they are called vibices. Petechise are met with in all dis- 
eases in which the proportion of fibrine in the blood is very much 
diminished. In typhoid fever they are rarely seen, but they are 
characteristic of that form of typhus which is most common in 
Great Britain and Ireland, and which has recently prevailed so ex- 
tensively among the emigrants from the latter country. 

The temperature of the human body is subject to a great many 
variations, even in a state of health. It is lowest at the two ex- 



TEMPERATURE OF THE BODY. . 233 

tremes of life, and highest at the middle of the period between 
them, but is constantly changing under the influence of external 
temperature, food, clothing, exercise, &c. Its average degree, 
as measured by Fahrenheit's thermometer, is about 100°. In 
disease it seldom rises more than two degrees above this point, 
although it has been observed, in a case of tetanus, as high as 
110|°. The depression of temperature in certain cases, is much 
more considerable, for in the cold stage of Asiatic cholera, 
the thermometer applied to the skin has fallen to between 70° 
and 80°. 

But the thermometer is seldom employed in pathological inves- 
tigations, except when the deviation from the natural standard of 
heat is very striking. Ordinarily, the sensations of the patient, 
and those received by the hand of the physician, furnish much 
more important indications; for it is not the temperature of the 
skin alone considered, which is the object of inquiry, but certain 
feelings, also, of dryness, moisture, pricking, and clamminess, 
which can only be appreciated by the touch. 

The patient may also feel very cold or warm, without its being 
possible to detect any departure from his natural temperature. 
This appears to depend upon the morbid sensibility of the nervous 
system, for it. is most frequently observed in nervous and hysteri- 
cal females, and in those who suffer from irregularity of the cata- 
menia. A person of this description may even be shivering all 
over, while the skin retains its usual heat. The writer has also 
seen a young man who had over-fatigued himself with a long walk, 
shaking as violently as if he were in a fit of the ague, although 
his skin was even warmer than natural. In speaking, then, of 
coldness and heat of the body, it will be understood that they are 
referred to as sensations, rather than states indicated by the ther- 
mometer. 

Coldness is an important pathological sign. It may exist in va- 
rious forms and degrees, either as a sense of simple loss of tempe- 
rature, attended with stiffness, pallor, and corrugation of the hands 
and feet, or other parts of the body ; or as a shuddering or horri- 
pilation, with a sensation of creeping in the back, accompanied, or 
not, with coldness of the extremities ; or, finally, as a chill or 

20* 



234 SEM BIOLOGY. 

rigor, in which there is, at the same time, loss of heat upon the 
surface of the body, and a more or less violent quivering or agita- 
tion of the muscles, chattering of the teeth, and paleness of the 
skin. 

Either of these conditions may last for a few minutes only, but 
the most violent are also of the longest duration. Sometimes the 
chill constitutes the whole disease, and continues until its fatal ter- 
mination, as in the more malignant cases of Asiatic cholera, of in- 
termittent fever, of peritoneal perforation, &c. ; but it, for the most 
part, forms the first decided symptom of the invasion of febrile and 
inflammatory diseases. It may occur once, or more frequently, 
during the attack, and either irregularly, or at regular intervals ; 
and it may occupy the whole body, or affect one part alone, 
as the chest, the lower part of the trunk, or a single extremity. 
It has even been known, in certain paroxysmal fevers, to be con- 
fined to a still narrower region, as one finger, or a circumscribed 
spot upon the face or trunk. Habitual coldness of the hands and 
feet is very common amongst nervous females, in persons of seden- 
tary habits, and in those who are troubled with indigestion and 
constipation. Not a few suffer from it exceedingly, during the first 
hour or two after eating a full meal, particularly if they remain at 
rest. Coldness is not unfrequently felt in a part about to become 
paralysed, in chronic affections of the spinal marrow, but in that 
case is generally accompanied with some loss of power, or with a 
tingling sensation, which indicates still more clearly the character 
of the threatened attack. This symptom belongs to all states in 
which the activity of the circulation in apart is diminished. Thus, 
it nearly always attends cyanosis, and other instances of cardiac 
disease, retarding the movement of the blood ; it is also produced 
in obstruction of arterial trunks, whether by ligature, as in opera- 
tions for aneurism of a limb, or by a fibrinous clot, as in arte- 
ritis. 

A chill occurring in the course of a disease which is not paroxys- 
mal, is generally a sign, either of an intercurrent inflammation, or 
of the occurrence of suppuration in a part already inflamed, and 
is, therefore, of evil augury. Thus, in the progress of continued 
fevers, such an occurrence renders it probable that an attack of 



COLDNESS HEAT. 235 

pneumonia, pleurisy, pericarditis, endo-carditis, or meningeal in- 
flammation, is about to take place; during the decline of typhoid 
fever, a severe chill is usually accompanied with abdominal pain, 
and is then a sign of peritonitis from perforation ; in the puerperal 
state, this phenomenon may accompany the establishment of the 
lacteal secretion, or, if the abdomen become tender at the same 
time, metro-peritonitis may be anticipated ; at a somewhat later 
epoch, it is more likely to threaten an attack of phlegmasia dolens, 
or the formation of an abscess in the mamma. After wounds, a 
rigor may precede the appearance of erysipelas, or inflammation 
of the veins, or the ordinary consequence of traumatic phlebitis, 
the formation of purulent deposits in the lungs, brain, liver, or other 
viscus. In the course of all parenchymatous inflammations, a chill 
denotes the advent of the suppurative stage. This is seen in sim- 
ple phlegmon, and in pneumonia. A like occurrence in phlegma- 
sia? of the serous membranes is said to announce that pus in- 
stead of serum has begun to be secreted. The daily recurrence 
of a slight chill, followed by fever and sweat, when it takes place 
in a chronic affection marked by debility and wasting, is called 
hectic fever, (sjcttjxw, I consume,) and if it attends organic disease, 
shows that the fatal issue of the attack is approaching. It does 
not, however, follow that hectic is always a fatal omen. It may 
occur in chronic bronchitis, in empyema, and in large exter- 
nal suppurations, and yet the patient recover. 

Heat, like coldness, may be general or partial, continuous, irre- 
gular, intermittent, and of various degrees of intensity. It is par- 
tial in most local inflammatory affections of the skin ; nervous in- 
dividuals frequently complain of heat, confined to very narrow 
limits. Phthisical patients are subject to a burning sensation in 
the palms of the hands and the soles of the feet ; but not they 
alone ; it is common in all affections attended with progressive ema- 
ciation and exhaustion. It is alleged that in consumption, a more 
intense heat is felt in the cheek or palm of the hand corresponding 
with the affected lung, than in those of the opposite side. This is 
certainly not an ordinary occurrence, but the writer has met with 
it in a young lady of highly nervous temperament, who died of pul- 
monary tubercles at the age of nineteen. For many months be- 



236 SEMEIOLOGY. 

fore the tubercular deposit could be detected by physical signs, 
and while she was under treatment for chronic follicular pharyn- 
gitis, the left cheek was, upon the least excitement, marked by a 
large and well-defined red spot, glowing with heat, while every 
other part of the face was very pale. The tubercles throughout 
their whole course were almost exclusively confined to the left lung. 

The following varieties of morbid heat may be admitted. 1st. 
Simple increase of temperature {color urens), with a dry, or 
moist and pliant, state of the skin. It is equably diffused over the 
whole surface of the body, is accompanied with a pulse at least 
above the natural standard, with increased frequency of the respi- 
ration, and usually with some local pain. It is characteristic of 
inflammatory diseases and fevers of an active or sthenic type. 
2d. Acrid heat {color mordax), which gives to the hand a certain 
undefinable stinging sensation. It is most frequently met with in 
fevers of an adynamic type ; in petechial typhus, scarlatina angi- 
nosa, and hectic fever. Zd. Nervous heat, which to the percep- 
tion of the patient has the same qualities as the first variety, but is 
not attended, usually, with any increase of temperature sensible 
to the hand of the physician. It is not febrile heat. It comes in 
flushes, and, when felt in the face, is sometimes accompanied by 
temporary redness of this part. It is common in persons of an 
irritable temperament, and in females generally, about the cessation 
of the menses. This symptom appears to be caused by sudden 
and momentary determinations of blood to various parts of the 
body. Its mechanism is thought to resemble that of blushing. 

Perspiration. — In health there is a large amount of fluid dis- 
charged from the skin in the form of an invisible vapour, or insensible 
perspiration : when the quantity of this fluid is increased by exer- 
cise, heat, &c, or the state of the atmosphere retards its evapora- 
tion, it accumulates upon the skin in the form of sweat. The va- 
rieties which it presents in quality, amount, and the circumstances 
under which it appears in disease, are of considerable importance 
in prognosis, for it will be remembered that of all the critical dis- 
charges, that by perspiration is the most common. 

When perspiration comes on during the decline of an acute at- 
tack, and occupies the whole surface of the body, and at the same 



PERSPIRATION. 237 

time the pulse grows fuller, softer, and slower, and the patient feels 
relieved, it may be looked upon as critical. Such phenomena al- 
ways attend the resolution of a paroxysm of regular intermittent 
fever. 

General sweats are more favourable than local ones, inasmuch 
as the former alone are critical ; but the latter occur, in general, 
over the affected organ, and sometimes indicate the passage of in- 
flammation into the suppurative stage. The perspiration which is 
so commonly observed upon the face in diseases of much prostra- 
tion, or as a result of severe pain, has no particular significance. 
In some persons there is an habitual discharge of perspiration from 
the feet, the armpits, or the neighbourhood of the genitals, and its 
suppression, whether occurring at the onset, or during the course 
of a disease, is much to be dreaded. In the gouty this event 
has been immediately followed by an attack of gout, and in the 
plethoric by apoplexy. 

Critical sweats take place more frequently between midnight and 
morning than at any other time, and although sometimes very co- 
pious, are oftener moderate in quantity, and followed by a marked 
sense of relief. Profuse perspiration is an ordinary attendant of 
acute articular rheumatism, but in that affection, rather add to than 
diminish the discomfort of the patient. The same observation 
holds good in regard to sweating with hectic fever, and all diseases 
marked by great debility. In these latter the fluid discharged is 
very apt to be cold. The night-sweats of phthisis are amongst the 
most unfavourable symptoms of the complaint. Frequently they 
alternate with diarrhoea, so that the suspension of the one by me- 
dical treatment, re-establishes the other, and no benefit accrues to 
the patient. These discharges when they are attended with rapid 
loss of flesh and increasing debility, are termed colliquative. 

The ordinary colour of the perspiration is that of water, but it is 
altered by the admixture of various substances which give it their 
appropriate hue. Thus, as already noted, it may become yellow 
in jaundice, and, more rarely, it is seen tinged with blood. Bloody 
sweats are not to be confounded with those vicarious sanguineous dis- 
charges from the skin which are occasionally met with in suppressed 
menstruation. These latter arc always confined to a verv narrow 



238 SEMEIOLOGY 






space, and are periodical. A case of bloody sweat is related by Boi- 
vin of a woman who was seized with hflematemesis after receiving a 
blow on the pit of the stomach ; this hemorrhage was stopped, but 
an exhalation of blood from various parts of the skin, continued to 
take place at irregular intervals for at least twenty years afterwards. 
Its appearance was preceded by itching and burning, and then 
drops of bright-coloured blood exuded from the pores of the skin 
wherever these sensations had been felt. The patient menstruated 
with perfect regularity. Other cases are mentioned by Fournier, 
and by Gendrin. In one the cutaneous hemorrhage followed ex- 
cessive mental application, and a night of inordinate venery; in 
another it appeared to be owing to a drinking debauch, and a fit of 
anger; the subject of it was a person who had previously enjoyed 
good health and led a sober life. Putrid fevers, so called, do not 
produce exhalation of blood from the skin, but into this tissue, and 
from the surface of mucous membranes. 

The natural odour of the perspiration is somewhat sour. This 
quality is exaggerated in rheumatism and in gout ; in low forms of 
fever it sometimes exhales an ammoniacal odour. Scarlatinous 
and variolous eruptions emit a peculiar mouldy smell ; typhoid 
fever one which is said to resemble that of mice ; favus has a pun- 
gent odour, compared by some writers to the smell of cat's urine. 
Foetor of the cutaneous exhalation is always an unfavourable sign 
in acute disorders ; it is of less consequence when it occurs along 
with obstinate constipation, as it sometimes does in the insane who 
refuse food for the purpose of self-destruction. The habitual food, 
or the air generally breathed by the patient, may impart an odour 
to his perspiration. This is observable in persons who are accus- 
tomed to eat garlic. Chomel relates that an ostler whom he was 
treating for a high bilious fever, smelled so strongly of the stable 
that every one who approached him became sensible of it, although 
he wore none of the clothes he had on before his illness. 

The sensibility of the skin furnishes important information; but, 
as its various conditions relate entirely to affections of the cerebro- 
spinal axis, they will be considered in the section devoted to the 
semeiology of the nervous system. 



EXPRESSION OF THE FACE. 239 



SECTION II. 

SIGNS FROM THE HEAD, FACE, AND NECK. 

The position of the head in diseases deserves a passing notice. 
It is inclined to one side in luxation of the cervical vertebra?, hemi- 
plegia, and wry-neck, by a wen or glandular swelling on one side, 
or by dense cicatrices of the skin covering the cervical region. 
In many cases of tetanus, and of spinal meningitis of the upper 
portion of the cord, which is frequently mistaken for tetanus, the 
head is rigidly flexed or extended. It takes the latter position, also, 
whenever there is difficulty of respiration arising from an obstacle 
in or near the windpipe or larynx, as in croup, oedema of the la- 
rynx, chronic ulceration, cancer, &c, of this organ. 

The size of the head is increased by internal as well as external 
agencies. In hydrocephalus and hypertrophy of the brain, both 
of them diseases of childhood, this condition is remarkable. In- 
flammation of the integuments causes a considerable swelling of 
the head. This is met with, almost exclusively, in erysipelas of 
the scalp and in small-pox. 

Although the diagnostic signs drawn from theface relate chiefly 

to its own diseases, it furnishes more, and better, indications on 

which to found a prognosis than any other part of the body. The 

physiognomy of men in health is universally held to be an index 

of their feelings, and mankind cling to a belief in its accuracy, 

notwithstanding the perpetually recurring instances of deception 

which they encounter. Physicians have much better reason to 

trust the physiognomy of the sick. It tells no lies. The patient 

knows that he has nothing to gain, but much to lose, by concealing 

the truth from his medical attendant; and if even he misleads him 

by false declarations, he generally sets him right by the involuntary 

testimony of his countenance. The healthy may for dishonest 

purposes feign disease, and so successfully, now and then, as to 

impose upon the most practised judgment, but the really sick do 



240 SEMEIOLOGY. 

not often attempt to simulate health. Disease gives to them an 
expression which cannot be mistaken, and which the experienced 
physician learns, at last, to interpret with wonderful precision, dis- 
cerning not only that the individual is ill, but where and what is 
his peculiar malady. This art can only be taught by pointing out 
in detail the significance of each particular alteration impressed 
upon the face by the action of its muscles, its colour, its fulness or 
emaciation, and the condition of the individual features. When 
these details are once known, it is comparatively easy to judge of 
the indications furnished by any number of them conjoined. 

Amongst the most remarkable changes which the face undergoes, 
are those which are owing to irregular or unequal muscular con- 
traction. Infantile convulsions are usually attended with great 
distortion of the features. In severe cases of chorea, all the mov- 
able parts of the face are seized with intermittent spasms ; the eyes 
and mouth are drawn first in one and then in another direction, 
producing a succession of grimaces which no one could possibly 
imitate. The features are also horribly distorted in the epileptic 
paroxysm, and in general tetanus. Spasm of the facial muscles 
often accompanies neuralgia of the fifth pair of nerves, especially 
in that terrible degree of it called tic douloureux ; but it is not ne- 
cessarily caused by intense pain, nor always accompanied by it; 
occasionally the spasm takes place without any evident cause, 
jerking the mouth violently to one side, or making the eye wink 
rapidly, without the patient being in the least degree able to control 
these annoying movements. 

A complete loss of power on one side of the face may exist as a 
part of hemiplegia, and also as a distinct and local affection. In 
the former case suspicion must be entertained of cerebral or spinal 
disease ; but in the latter the palsy is nearly always due, either to 
the direct influence of cold, or to some disease of the bone, or of 
the soft parts, in the course of the portio dura of the seventh pair. 
On the paralysed side the face loses its natural expression; the 
mouth is no longer symmetrical, the commissure of the affected 
side is drawn towards the median line ; the cheek hangs loosely, 
the upper eyelid droops, veiling the cornea entirely, and no wrinkles 
are to be seen on that side of the forehead. It is important to note 



COLOUR OF THE FACE. 241 

the earliest development of these symptoms, in the progress of 
diseases of the nervous centres, and in persons subject to a deter- 
mination of blood to the head, because they not unfrequently in- 
dicate the approaching danger before any loss of power is expe- 
rienced in either of the limbs. 

The colour of the face is extremely variable, even amongst 
healthy persons; in many the complexion has a florid, or almost 
crimson hue ; in many it is pale, almost to whiteness. The de- 
gree of plethora, however, which the former state reveals, tends to 
the production of apoplexy, unless relieved by epistaxis, or some 
other salutary hemorrhage. In all of those affections in which it 
has been stated that the skin grows red, the face is tinged more 
deeply than any other part. Upon it, too, and because, probably, 
of the great development of its capillary vessels, inflammatory 
eruptions are peculiarly frequent; and those of them which cover 
the whole surface, are usually more developed upon the face than 
elsewhere. The confluence of variolous pustules upon this part, 
while the rest of the body is but moderately attacked, presents a 
familiar instance of the sort. The vividness of the colour, what- 
ever may be its cause, is nearly always proportioned to the acute- 
ness and activity of the disease. In diseases of a low form, the 
face is of a dusky red colour; in those of a chronic type, attended 
with exhaustion and fever, there is generally a bright and circum- 
scribed redness of the cheek, which contrasts strikingly with the 
cadaverous pallor of the rest of the face, and is familiarly known 
as a " hectic flush." It is said that in pneumonia the redness is 
often confined to the cheek of the same side with the affected lung, 
a circumstance which probably depends upon the patient's usually 
lying upon that side. Grisolle found in his observations upon this 
disease, that where the patient lay upon his back, the reddened 
cheek corresponded with the inflamed lung no oftener than with 
the sound one; that very often there was no increase of colour 
at all in the face; and that when it existed, it was, as a general 
rule, upon both sides, and appeared only during the active stages 
of the disease. Lividity of the face indicates that some impediment 
exists to the return of venous blood to the heart. The usual seat 
of the obstruction is either in this organ, or in the lungs. It is in 

21 



242 SEMEIOLOGY. 

the face that nearly all the alterations of colour which have been 
pointed out first become manifest. 

Paleness of the face is a very constant mark of disease. It is 
met with at the commencement of nearly every acute disorder, 
and accompanies the stage of coldness or depression which pre- 
cedes that of reaction and fever ; in chronic complaints it usually 
goes on increasing with the advance of the disease ; and it always 
attends the period of convalescence. It is most strongly marked 
after profuse hemorrhage, and immediately before dissolution, 
whenever death is owing to exhaustion. It is greatly modified by 
admixture with the other shades of colour which have been indi- 
cated as belpnging to various morbid conditions, particularly with 
the lividity of venous congestion, and the yellowness of jaundice. 

The general expression of the countenance cannot be too care- 
fully studied. While the mind is sound, a serene or hopeful coun- 
tenance presages well; for although it is often only a sign of resig- 
nation to an inevitable fate, it even then indicates a spirit which 
tends greatly to prolong life, and where the issue is more uncer- 
tain, one that may turn the balance in favour of recovery. A 
morose, peevish countenance is a sign of abdominal disease, and 
contortion of the features an indication of abdominal pain. The 
latter condition, with continued shrill crying, distinguishes the colic 
of infants from most of the other pains to which they are subject. 
A wild or fierce look is characteristic of maniacal delirium, and 
mania ; one of sadness or anxiety is said to be worn by persons 
suffering from hepatic disease, — it is also the habitual expression 
of insane melancholy; a vacant, heavy, or silly countenance be- 
longs to the idiotic and imbecile, and is not unfrequently observed 
during convalescence from typhoid fever, and other severe diseases 
attended with cerebral disorder. It is then very apt to be a pre- 
lude to incurable dementia. 

But the most dangerous of all the signs furnished by the coun- 
tenance, is that condition of the features known as the facies hip- 
pocratica, and so called after Hippocrates, who thus describes it. 
"The nose is sharp, the eye-brows knitted, the eyes hollow and 
sunken, the ears cold, contracted, and their lobes shrivelled ; the 
skin about the forehead is hard, tense, and dry, and the face pale, or 



EXPRESSION OF THE FACE THE EYES. 243 

of a greenish, livid, or leaden hue. If the patient has been exces- 
sively fatigued, or has suffered from diarrhoea or starvation, this 
sign is less untoward; but arising from any other cause, and so 
continuing without change for twenty-four hours, a speedy death 
may be predicted." It would scarcely be possible to render this 
picture more perfect, or add anything to the caution which is given 
in regard to interpreting it. The fades hippocratica may be seen 
in many cases of great and rapid exhaustion, without its betoken- 
ing a fatal issue; but if within twenty-four hours reaction does not 
take place, and it rarely does so in diseases which have already 
extended beyond a week, there is not the least ground on which to 
build a hope of cure. 

The eyes and their appendages. — The eyelids, like other mus- 
cular parts, are feebly moved in low fevers, and nearly conceal 
the ball of the eye : they not only hide it, but strongly oppose 
being opened in those forms of ophthalmia which are attended 
with intolerance of light. In paralysis of the portio dura, the 
orbicularis ceases to contract, the lids remain open, and ex- 
pose the parts beneath to the irritation of the air and dust, which 
soon excites severe inflammation. Paralysis of the third pair de- 
prives the upper lid of motion, and effectually shuts out light from 
the eye. If this condition coexist with loss of power on the oppo- 
site side of the body, cerebral disease may be inferred. Otherwise 
it may be owing to a blow upon the superciliary ridge, or to rheu- 
matism of the levator muscle, or to a tumour or other disease within 
the orbit. An open state of the eyelids in sleep may be owing to 
spasm of the levatores ; some writers have attributed it in children 
to verminous disease, but many individuals in perfect health habi- 
tually sleep with their eyes half open. 

The tears, instead of being absorbed by the punctre lachry- 
males, may run down upon the cheek. This indicates, usually, 
obstruction of the lachrymal duct. It occurs at intervals, when the 
nerves around the eye are attacked with neuralgia; commencing 
inflammation of the conjunctiva, also excites a profuse flow of tears. 
The accumulation and hardening of the palpebral mucus upon the 
edges of the lids indicates an extreme degree of prostration. 

The expression of the eye, and its changes in position, form, 



244 8EMEIOL0GY. 

colour, brightness, and power of vision, possess a very decided in- 
terest in connexion with the present subject. The eyes are unusu- 
ally bright during high fever with maniacal delirium, but dull and 
hazy in low fevers, and all affections in which there is sluggishness 
of the intellect or stupor. The cornea becomes still more com- 
pletely clouded upon the approach of death, and often flakes of 
mucus partially obscure its surface. Immobility of the eyes may 
depend either upon paralysis of their muscles, or upon nervous 
spasm. It rarely happens that both eyes are paralyzed, except 
from extensive disease within the brain; cerebral disorganization, 
whether occurring near the orbit, or in the neighbourhood of the 
roots of the third, fourth, and sixth nerves, is more apt to paralyze 
the muscles of only one eye. Fixedness of the eyes is observed in 
some inflammatory affections of the brain, along with rigid and 
open lids, and constitutes what is called extasis ; in cataleptic fits 
the eyelids remain open, and the eyes, like the rest of the body, 
are immovable. In epilepsy, chorea, and other true convulsive 
diseases, the movements of the eyes are rapid, irregular, and often 
distorted. 

Squinting, or strabismus, besides being natural, or acquired by 
imitation, and so far of no importance as a sign, may depend upon 
disease within the cranium, or in the orbit. Conjoined with cere- 
bral symptoms, it is of most unfavourable significance in adults, 
but far less so in young children, in whom squinting may arise from 
various causes unconnected with disease involving life. Tumours 
&c, of the orbit often produce strabismus either by pushing the ball 
of the eye to one side, or by paralyzing a portion of the muscles. 
Rheumatism of these parts occasionally induces squinting. In a 
case of the sort under the writer's care, the eye did not regain its 
natural position for several months. 

Morbid prominence of the eye depends upon the turgid state 
of structures lying behind it, and often conveys a deceptive im- 
pression of the size of the organ. Protrusion of the eye, when 
gradual and permanent, is a sign of a tumour developed behind 
the eyeball, as enlargement of the lachrymal gland; encysted, 
fatty, bony, or cancerous tumours; aneurisms, and other tumours 
extending from the cerebral, nasal, or maxillary cavities, into the 



STATE OF THE EYES. 245 

orbit; an effusion of blood behind the ball; and finally, inflamma- 
tion of the cellular tissue at the bottom of the orbit. The eyes are 
hollow and sunken in all cases of general emaciation, owing to the 
removal of the layer of fat at the bottom of the orbit, and is of no 
further significance than as it marks the progress of emaciation. 
It is frequently very striking after sudden and exhausting dis- 
charges, such as diarrhoea and venereal excesses, although the 
general bulk of the body may not seem to be diminished. 

Vascularity of the conjunctiva frequently accompanies inflam- 
mation and congestion of the brain, but is more strongly marked 
when the membrane is itself inflamed. The sclerotic coat is usu- 
ally the part which first becomes yellow in jaundice ; in phthisis 
it acquires a pearly whiteness. In rheumatic ophthalmia and iritis it 
is marked by a radiated redness around its junction with the cor- 
nea. Ulcers of this latter tissue are most apt to occur in scrofu- 
lous persons, either from direct injury or after small-pox, and to 
leave behind them opaque cicatrices. Discolouration of the iris, 
and a fibrinous deposit upon it, with irregularity of the pupil, are 
signs of iritis. In the syphilitic form of this inflammation the 
pupil is said to be drawn upwards and inwards. 

The humours of the eye undergo a real or apparent change of co- 
lour in several diseases. The aqueous humour may be mingled with 
pus ; the crystalline become opaque and of a white or buff colour ; 
and the vitreous humour sometimes appear green. The last-named 
hue is merely apparent, and is believed to be caused by the reflection 
of the blue of the choroid coat through an amber-coloured lens, these 
two colours by their union producing green. The pupil is gene- 
rally dilated when sight is impaired by imperfection of the visual 
power, or by central opacity of the lens. The former state attends 
the various forms of amaurosis, and many cases of diseased brain 
without active inflammation. Exaltation of the functions of the 
brain and of the retina, most commonly occasions contraction of 
the pupil. The action of certain medicines on the pupil should 
be kept in mind. It contracts under the influence of opium, but is 
widely dilated by stramonium and belladonna. 

The forehead is the seat of headache in fevers, and is then 
hotter than other parts of the surface. It is an ordinary seat of 

21* 



246 SEMEIOLOGV. 

pustular syphilitic eruptions, and of syphilitic affections of the pe- 
riosteum and bones. The nose is commonly blunt and clumsy 
in scrofulous persons, but thin and pointed after exhausting disease. 
The nostrils expand forcibly in difficult respiration ; in hemiplegia, 
the nostril of the paralyzed side is apt to be closed during strong 
inspirations. Itching of the nose is one of the most ordinary signs 
of worms, or rather of that disorder of the digestive functions 
which is frequently accompanied with intestinal worms. It also 
precedes epistaxis. This hemorrhage, like the others, may be 
merely a sign of repletion, and is frequent during adolescence ; 
but it is also amongst the earliest symptoms of some diseases, and 
particularly of typhoid fever. It also coincides with diminished 
fibrin, and with other morbid states of the blood, as in scurvy and 
purpura. 

The lips, and the upper one especially, are swollen in persons 
of scrofulous constitution, and are subject to chronic eruptions. In 
cerebral congestion and apoplexy they are loose, and are alter- 
nately puffed out and drawn against the teeth as the patient 
breathes. When one side only of the face is paralyzed they in- 
cline to the sound side. In inflammation and in sympathetic dis- 
order of the brain, or nervous centres, the corners of the mouth 
are frequently retracted, so as to imitate a smile. This is a com- 
mon occurrence during the dentition of infants, who are thought to 
be smiling in their sleep, while they are in reality undergoing a 
slight convulsion. The movement in question is called risus sar- 
donicus. A tremulous movement of the lower lip occurs in ataxic 
fevers, and, as indicating great exhaustion, is of evil augury. The 
lips are blue or livid in cyanosis and other extreme venous con- 
gestions ; they are dry and incrusted in typhoid affections ; and 
become cold and colourless upon the approach of death. 

The lower jaw is firmly set against the upper in tetanus ; is 
fixed and extended in dislocation of the bone ; it rattles against 
the upper jaw in violent chills ; and generally falls by its own 
weight when dissolution is near at hand. The ears are, in the last- 
named circumstance, pale, pinched, and cold. A purulent discharge 
from the auditory canal, when of an offensive smell, is a sign of 
caries of the middle ear, and when to it are superadded cerebral 



THE FACE, HAIE, AND NECK. 247 

symptoms, fatal inflammation of the brain from caries of the pet- 
rous bone is indicated. A discharge of blood from this canal, after 
violence to the head, warrants the suspicion of fracture of the base 
of the skull. 

The hair very commonly falls out after eruptive diseases and 
typhoid fever, and after erysipelas and eczema of the scalp. Alo- 
pcecia in consequence of these affections is not irremediable, but 
favus, which destroys the hair-bulbs, produces incurable baldness. 
Prolonged or violent grief may turn the hair white, and the same 
is true of insanity. Severe febrile attacks have occasionally a 
similar effect. Cases are now and then met with in which a single 
lock of hair becomes white at an early age, and so continues 
through life. A writer mentions having seen brown hair become 
red during an attack of chlorosis, and subsequently regain its ori- 
ginal colour. Another records a similar case, except that while 
the chlorosis lasted the hair was perfectly white, or rather the part 
of it which had grown meanwhile ; on the patient's recovery every 
hair was brown at each end and white in the middle. 

A long, thin neck, with a narrow chest, is generally regarded as 
a sign of constitutional predisposition to phthisis, and a short and 
thick neck as showing a tendency to apoplectic affections. The 
large number of exceptions to these statements deprives them of 
much semeiological value. Enlargement or swelling of the neck 
is frequently observable in the first months of pregnancy, and in 
young females upon the approach of puberty. The lower part of 
the neck is increased in size by hypertrophy of the thyroid gland, 
or goitre, and its middle and upper portions by enlargement of the 
parotid, the submaxillary, or the lymphatic glands. The parotids 
are enlarged in mumps, and sometimes in typhoid fever, in which 
latter case they are very apt to suppurate. The submaxillary 
glands become tumefied in mercurial stomatitis. The lymphatic 
glands of the neck may be swollen during any acute inflamma- 
tions of the parts whence their vessels arc derived, as in erysipelas 
of the face and scalp, in tonsillitis, and sore throat, particularly 
that form of it which occurs in scarlet fever; in all of which cases 
there is more or less tenderness of the glands, and a tendency to 
suppuration. In chronic ulceration of the posterior fauces, those 



248 SEMEIOLOGY. 

bodies increase in size and remain swollen for a long period. 
Scrofulous enlargement of these glands, however, is a more ob- 
stinate affection. It is most usual in childhood, and is owing to a 
deposit in them of tuberculous matter. According to the best au- 
thorities, when they have become hardened by this deposit they 
either remain permanently enlarged, or their contents soften and 
are discharged, leaving fistulous ulcers, and ultimately indelible 
scars. In after life these marks may lead to the detection of scro- 
fulous complications which would have been, but for them, unsus- 
pected. 

The neck is one of the first parts to show the progress of ema- 
ciation. When the tricuspid orifice of the heart is patulous, it per- 
mits a regurgitation of the blood, which causes a pulsatory motion of 
the veins of the neck, particularly of the external jugular. This 
is called the venous pulse. The carotid arteries throb violently in 
hypertrophy with dilatation of the left ventricle of the heart, and 
also when there is inflammatory disease or active congestion with- 
in the cranium. 



SECTION III. 

SIGNS FROM THE EXTERIOR OF THE TRUNK. 

The form of the thorax varies according to age, sex, and tem- 
perament; being more prominent and capacious in males and in 
persons, generally, of a sanguine temperament, and of smaller di- 
mensions in females and nervous individuals of both sexes. M. 
Woiliez, who investigated with great labour and accuracy the re- 
lations of the form, capacity, &c, of the chest to various diseases, 
arrived at a result confirmatory of the general belief, that narrow- 
ness of the upper part of the chest, as well in its transverse, as in 
its antero-posterior diameter, indicates a predisposition to tubercular 
disease. This gentleman found, however, that of the consumptive 
patients examined by him about one-third were not remarkable for 
contraction of the upper part, of the chest. It is to be remembered 



FORM OF THE CHEST. 249 

that after phthisis has gone to the extent of producing emaciation, 
the wasting of the pectoral muscles will diminish the apparent 
size of the thorax. Depression of the spaces above and below the 
clavicles is usual in this disease at a very early stage, in conse- 
quence probably of local pleurisy and retraction of the integuments 
above the summit of the lungs, resulting from a deposit of tuber- 
cles in this portion of the pulmonary tissue. For obvious reasons, 
this sign is very strongly indicative of tubercles when it exists on 
one side only. A more extensive contraction of the thorax, one, 
for example, extending to the whole of one side of the chest, is 
produced by a similar mechanism. The lung, being compressed 
by a serous or purulent effusion, and bound down by false mem- 
branes, does not always expand in proportion as the effusion is re- 
moved ; the pressure of the atmosphere, therefore, forces the ribs 
inwards, making the shoulder of the affected side droop, and giving 
the person a very awkward carriage in walking. 

Dilatation of the thorax is rarely general ; but it often affects the 
whole of one side when the pleural cavity is distended with fluid 
or gas. In these cases the intercostal spaces are more prominent 
than the ribs. Dilatation from pulmonary emphysema is rarely so 
extensive ; in general it is most considerable at the upper and an- 
terior portion of the chest, between the clavicle and the nipple. 
Other local enlargements of the chest may be due to hypertrophy 
of the heart, effusion into the pericardium, aneurism of the ascend- 
aorta which shows itself at the junction of the third rib of the 
right side with the sternum, and aneurism of the descending aorta 
which forms a tumour between the base of the scapula and the 
spine. In all of these dilatations, whether general or partial, the 
sound on percussion is duller than natural, except in emphysema 
and pneumothorax, which give a loud resonance. In all, more- 
over, the natural sounds detected by auscultation are either feebler 
than in health, or are replaced by morbid murmurs. 

By inspecting the exterior of the thorax, the mode in which the 
patient breathes is ascertained. The number of inspirations in 
a minute is, for a healthy adult, about sixteen, and for an infant, 
twenty-five, but they are rendered much more frequent whenever 
an obstacle exists to the proper aeration of the blood, as in phthisis. 



250 SEMEIOLOGY. 

emphysema, pleurisy, disease of the heart and pericardium, &c, 
and when, as in febrile affections, the heart pulsates more rapidly 
than natural. In the former complaints, whatever even tempora- 
rily augments the number of cardiac pulsations renders the inspi- 
rations more frequent and quick. As in normal breathing the 
lungs are dilated as well by the descent of the diaphragm as by 
the elevation of the ribs, so when either of these agents is impaired, 
the other acts with additional energy. When the abdominal vis- 
cera, and the peritoneum especially, are inflamed, the movements 
of the chest are rendered more active, because the pain produced 
by the rise and fall of the diaphragm forces this muscle to remain 
at resl. Under these circumstances, the respiration is said to be 
high. On the other hand, when pain in the muscles or nerves of 
the thorax, or large effusions into its cavities interfere with its free- 
dom of action, the diaphragm moves through a larger space, and 
causes alternate rising and falling of the abdomen. The respira- 
tion is then called abdominal. For similar reasons one side of the 
chest may remain almost entirely stationary while the movements 
of the other are greatly augmented. 

In its natural state, the abdomen is soft and yielding, and, ex- 
cept from obesity, does not attract attention by its size ; disease, 
however, produces on its external covering, and in the condition 
of its viscera, numerous interesting and important changes. The 
integuments of this region are generally smooth and white, but in 
some women who have borne children, and in persons of either 
sex who have suffered from ascites, may be found irregular whitish 
streaks or wrinkles in the hypogastrium, resembling cicatrices, and 
which, indeed, indicate a superficial tearing of the skin at these 
points. A brownish line extending from the pubis to the umbili- 
cus, or higher, is frequently seen in pregnancy, of which it may 
therefore be considered a sign. The skin of the abdomen is the 
ordinary seat of the lenticular rose-coloured spots which are so 
characteristic of typhoid fever. 

Abdominal pains, for the most part, belong to one of two classes; 
those which arise from inflammation and are aggravated by pres- 
sure, and those which pressure relieves, and which are either 
owing to over-distention of the intestinal tube, or other visceral 



ABDOMINAL PAINS. 251 

canals, or to neuralgia. The pains of flatulent and painter's colic, 
and of those severe attacks produced by the passage of a calculus 
through the biliary ducts, or ureter, are examples of the second 
class. In general, the seat of pain will indicate pretty nearly the 
organ in which it originates ; but not always. The colon, in its 
extensive circuit, lies in contact with the kidneys, liver, stomach, 
&c, and its own pains may be mistaken for those of the several 
organs mentioned. Other functional disorders must therefore be 
appealed to in forming a diagnosis. In that disease, so rare as an 
independent affection, acute gastritis, the epigastrium is the seat of 
soreness, which becomes decided pain upon pressure ; pain in cancer 
of the stomach, when it exists at all, is sharp and lancinating, and 
soreness is felt under pressure; in gastralgia the pain is extremely 
acute, lancinating, or cramp- like, and paroxysmal ; many cases of 
indigestion are attended with dull or burning epigastric pain and 
soreness, and some of them are complicated with gastralgia. 
When the small intestines are inflamed, there is little or no spon- 
taneous pain, excepting what is colicky, and which, arising around 
the umbilicus, radiates to all parts of the abdomen. But there is 
much tenderness upon pressure. In dysentery the character of 
the morbid sensation is very similar, but, in addition, there is a 
sharp, burning pain in the rectum, accompanied with tenesmus, or 
an irrepressible desire to go to stool. Hemorrhoids, simple inflam- 
mation of the rectum, and pressure upon this bowel by contiguous 
bodies, (stone in the bladder, prolapsed womb, pelvic tumours, &c.,) 
produce a like result. 

Tormina, or acute colicky pains, are met with in various intes- 
tinal disorders. It is inferred, from the circumstances under 
which they occur, that they depend upon spasm of the muscular 
coat of the intestine; since, on the one hand, they are connected 
either with over-distention of this tube by gas or faeces, ceasing on 
the evacuation of these matters, or else with firm contraction of the 
bowel, as in painter's colic. They may accompany inflammation 
of the intestinal mucous membrane; or be due to the presence of 
undigested, and therefore irritating, substances ; or accompany 
simple diarrhoea produced by cold ; or exist at the outset of an 
attack of intus-susception, or other obstruction of the bowels ; or 



252 SEMEIOLOGY. 

accompany spinal neuralgia; or, finally, depend immediately upon 
the poisonous action of the salts of lead. Whenever gentle pres- 
sure upon the abdomen does not assuage them, or adds to the 
patient's suffering, it must be inferred that they are complicated 
with inflammation, either of the intestinal mucous membrane or of 
the peritoneum. This latter state gives rise to a severe pungent 
pain, which may be very inconsiderable so long as ihe patient re- 
mains perfectly motionless, but is augmented by the slightest move- 
ment, and even by the tension of the abdominal parietes when the 
lower limbs are extended. Its distinguishing characters are its 
being constant, and so superficial, that the gentlest touch of the 
abdomen excites it; contrasting thus with tormina, which are re- 
mittent, and with the pain of mucous inflammation, which is deep- 
seated. 

Pain in the parenchymatous organs of the abdomen is dull and 
heavy; it is increased, but not rendered sharp, by pressure, so long 
as the peritoneum is intact. The acute pains referred to these 
organs when inflamed, or otherwise diseased, generally depends 
upon circumscribed inflammation of their peritoneal coat. Pain in 
cancer of the liver, for instance, has been shown to depend upon 
this cause; and the sympathetic pain, so called, which is then 
sometimes felt in the right -shoulder, has also been shown to coin- 
cide with the existence of cancerous masses upon the upper surface 
of the organ, which, it is supposed, irritate, by their contact, the 
branches of the nerves supplying the diaphragm, and by a reflected 
action excite pain in the shoulder. A peculiarity of the pain ex- 
cited by renal calculi, is, that it darts along the ureters, and is felt 
in the groin, while the testicle of the affected side is usually re- 
tracted. In like manner, pain in the bladder extends along the 
urethra to the glans penis ; and pain in the uterus to the groins, 
the thighs, and the loins : phenomena explicable by the nervous 
connexions of the parts. 

The abdomen diminishes in all diseases attended with general 
emaciation, unless a tumour or ascites be present; it is singularly 
hollow in chronic dysentery, its anterior parietes almost touching 
the spinal column, and displaying the pulsations of the abdominal 
aorta. In lead-colic, also, the walls of the abdomen are greatly 



DISTENTION OF THE ABDOMEN. 253 

retracted, and feel quite hard and stiff when pressed upon. The 
belly may be alternately distended and contracted when the rec-_ 
turn or lower bowels are strictured, according as the parts above 
are filled with, or freed from, the fasces which sometimes accumu- 
late in them to an enormous extent. The dimensions of the ab- 
domen may be increased in disease by air, serum, faecal masses, 
or tumours. Distention by gas is called meteorism, or tympanites. 
It occurs, as before stated, in hysteria, in peritonitis, also in typhoid 
fever, and in obstruction of the bowels. Unless excessive, it is 
of itself unattended with danger. 

Abdominal tumours consist either of hypertrophied or distended 
viscera, or of abnormal growths. Enlargement of the liver, spleen, 
and kidneys ; distention of the bladder by urine, and of the womb 
by a foetus, are examples of the first sort ; the formation in the 
ovary and other organs of cysts, or of scirrhus, encephaloid, and 
tuberculous deposits, belongs to the second class. In following 
out the history of an abdominal tumour, it is very necessary to 
determine exactly the point where it first appeared, because in this 
manner may be ascertained the organ to which it is attached. If 
a tumour is not examined until after it has attained its full develop- 
ment, and when it has contracted adhesions to the abdominal walls, 
and by its pressure interfered with the functions of different organs, 
it is often quite impossible to decide either upon its origin or its 
character, whereas if its starting-point has been accurately deter- 
mined, and its progress attentively observed, both of these particu- 
lars may be ascertained with comparatively little difficulty. A 
large tumour of the lower part of the belly, for instance, may be 
plausibly assigned either to the uterus or ovary; but if seen when 
small, its position under the linea alba, or to the right or left of this 
line, will be almost sufficient to determine its seat. 

The form of a tumour, when taken in connexion with its situation, 
often renders important aid in diagnosis. Thus, when it retains 
the shape of the organ belonging to the region where it is developed, 
the presumption is in favour of its being a simple enlargement or 
distention of that organ. A smooth, globular, swelling in the hy- 
pogastric, if of slow growth, may fairly be regarded as the dis- 
tended uterus ; a similar one in either iliac fossa, as ovarian 

22 



254 SEMEIOLOGY. 

dropsy ; a projection in the right or left hypochondrium without 
irregularity of surface, and occupying the space usually filled by 
the organs lodged in those regions, as an enlargement of the liver 
or spleen. But, if in any of these situations there is a tumour of 
irregular shape, and studded with projections, it may be inferred 
that it is composed of some heterologous deposit, or a congeries of 
cysts. The liver, spleen, kidneys, ovaries, uterus, and mesentery, 
are all subject to carcinomatous enlargements, sometimes of extra- 
ordinary dimensions, and all of them marked by these character- 
istic protuberances. The mesenteric glands, indeed, may be 
enormously enlarged by a deposit of tuberculous matter in them, 
but this rarely occurs subsequently to childhood, and cannot, there- 
fore, be easily confounded with cancer of the same part, which is a 
disease of the decline of life. When cancer affects the hollow or- 
gans, the rough surface of the deposit is towards their cavity, so 
that the hand can only reach the smooth or peritoneal surface of 
the tumour. In such cases the general symptoms must clear 
up the diagnosis. It is certain however that any permanent 
intestinal tumour ought justly to excite suspicion of its being 
cancerous, or as susceptible of cancerous degeneration, for 
there are none others of the digestive canal, except such as arise 
from retained feeces or flatus. Even these are sometimes due to 
intestinal cancer, particularly that of the rectum ; the freces accu- 
mulate in the sigmoid flexure and the descending division of the 
colon, and produce a large tumour. They may arise in other 
parts, in consequence of hernia, stricture, intus-susception, com- 
pression, or any other mode by which the canal may be obstructed. 
Stercoraceous tumours can frequently be recognised by their feel 
alone ; they offer a certain degree of resistance without elasticity, 
and pit upon pressure. Encysted liquid tumours are elastic, and 
often manifest an obscure degree of fluctuation. Cancerous tu- 
mours are, for the most part, hard and inelastic, and never fluctu- 
ate. It is true that certain different conditions are sometimes 
united in the same tumour ; encysted dropsy of the ovary, for ex- 
ample, may be connected with cancerous degeneration. In cases 
of this sort, the constitutional symptoms must be appealed to for 
the solution of whatever difficulties remain after a physical exami- 



ABDOMINAL TUMOURS. 255 

nation. Indeed, wherever both modes of investigation are appli- 
cable, both should be employed. 

To complete this succinct account of the signs of disease furn- 
ished by the exterior of the body, it only remains to notice those 
belonging to the limbs, and to the external organs of generation. 
But the former have in a great measure been included in the notice 
taken of the general surface, and the latter will hereafter be treated 
of in a more appropriate place. We proceed therefore to consider 
the semeiology of the interior of the body. 



CHAPTER II. 

SIGNS FROM THE DIGESTIVE APPARATUS. 

The mouth undergoes a great many changes in disease. In 
many cases of epilepsy and hysteria it is more or less constantly 
closed, and in tetanus, as before remarked, cannot be opened even 
by force. All swelling and inflammation of the glands or cellular 
tissue adjacent to the angle and ramus of the jaw, or of those in 
the posterior fauces, prevent its being more than partially opened, 
and that at the expense of great suffering. In low forms of fever, 
on the other hand, whenever there is extreme prostration, in idiocy 
and dementia, in apoplexy and in luxation of the lower jaw, the 
mouth is generally open ; this is an almost unfailing symptom in 
the moribund. Caries of the teeth, according to some writers, in- 
dicates habitual irregularities of indigestion ; but this is far from 
being established, although the extreme prevalence of dental caries 
and of dyspepsia in this country as compared with Europe, lends 
some probability to the statement. Carious teeth may excite seve- 
ral diseases, or prevent their cure ; such as caries of the maxilloe, 
abscesses and ulcers of the teeth and gums, enlargement of the 
lymphatic ganglia of the neck, and occasionally, although not as 
often as is generally imagined, neuralgia of the fifth pair. The 
gums become soft and swollen in scurvy and from the influence of 
mercury; in the former they are of a dark or brownish-red, and 
in the latter of a bright red colour. Rostan states that scorbutic 
swelling is never seen in gums which have long before lost their 
teeth. Amongst workers in lead, a gray line may be seen extend- 
ing along the gums parallel to, and at a short distance from, their 
attachment to the teeth, which in these persons rapidly decay. 

The lining membrane of the mouth is pale in anemia, of a 
dusky-red in low fevers and scurvy, and purplish or of a leaden- 



THE MOUTH AND BREATH. 257 

hue in cyanosis. In sthenic inflammations of other parts, and when 
itself inflamed, it acquires a much brighter tinge than natural. It 
is the seat of diphtheritic formations originating with itself, or oc- 
curring as complications of febrile disorders attended with great 
exhaustion. It is very subject to aphtha?, which are inflamed fol- 
licles situated on the tongue, the cheeks, or more frequently upon 
the inner surface of the lower lip. They are commonly a sign of 
intestinal disorder. The ulcers which may be met with in the 
mouth are chiefly of three kinds, the scorbutic, the syphilitic, and 
the mercurial, and may generally be distinguished from one another 
by their physical characters. Scorbutic ulcers are bloody, fun- 
gous, and seated upon the gums; syphilitic ulcers are round, ex- 
cavated, and their bottom is covered with a grayish matter ; they 
usually attack the soft palate, the tonsils, and the pharynx ; finally, 
mercurial sores are large, whitish, and superficial, and are accom- 
panied with considerable swelling and heat. They occupy the in- 
ternal surface of the cheeks and lips, and corrode the gums around 
the teeth, especially the last molars. 

The breath acquires an unnatural smell in various diseases. In 
nearly all attended with fever it is heavy and disagreeable, but in 
those of great prostration it is generally sickening and repulsive. 
On the approach, and during the progress, of salivation, it has a 
metallic odour; in saturnine diseases its smell is like that of gar- 
lic ; and in the diptheritic affections of the mouth and fauces, it is 
insupportably foetid. This foetor however is not necessarily a sign 
of gangrene. In gangrene of the lung the breath and sputa have 
a smell which is sickening and foetid to the last degree, and has 
been aptly compared to the odour exhaled by wall-plaster when 
fresh. 

In all ages the tongue has been thought to furnish important in- 
formation in disease, as well by those who have really studied its 
various conditions, as by the practitioners who have made its in- 
spection a mere occasion for mysterious looks, and oracular re- 
marks. Its size and shape, and the characters of its coating have, 
at different times been looked upon as positive diagnostic signs of 
disease; but these exclusive views have rarely outlived the persons 
who respectively gave them currency. Yet the conditions of this 

22* 



258 SEMEIOLOGY. 

organ and of its functions, have in reality such a value as to en- 
title them to a full consideration. 

The tongue is the principal organ of the sense of taste, which 
is almost uniformly modified by disease. There is no more fre- 
quent sign of impending sickness than the loss of a natural relish 
for food, and no surer indication of returning health than the re- 
covery of this relish. The sick rarely receive from sapid bodies 
the same impressions as in health ; all the food prepared for them 
is equally insipid, nauseous, or bitter, or they have constantly a 
perception of some one of these or other tastes. The insipid taste 
accompanies, especially, inflammation of the respiratory passages, 
including the nostrils, posterior fauces, and air-tubes. A bitter 
taste is most frequently experienced in dyspepsia, particularly in 
that form of it attended with eructation or vomiting of bilious mat- 
ter, and, occasionally, in those more distinct derangements of the 
liver depending upon inflammatory or structural disease of this 
organ, and which are accompanied with jaundice. An acid taste 
prevails in those other forms of dyspepsia in which sour regurgi- 
tations take place, and also in cancer of the stomach. A salt 
taste in the mouth is a common precursor of hoemoptysis. A foul or 
putrid taste is generally due to diphtheritic inflammation, to sup- 
puration, or to gangrene of some of the parts connected with the 
mouth, as the nose, throat, oesophagus, or lungs. It is also present 
in cases of obstinate and prolonged constipation. A metallic taste 
is usually the first sign of the constitutional influence of mercury ; 
it is said also to occur in intermittent fever. In hysteria, hypo- 
chondria, and chlorosis, the taste is frequently perverted, and per- 
sons suffering under these complaints have often perceived the most 
exquisite flavour in chalk, charcoal, slate, and even in animal sub- 
stances far gone in putrefaction. It is impossible to refer all of these 
morbid conditions of the sense of taste to an uniform cause. Some 
of them appear to be owing to the coating upon the tongue, while 
others may with more probability be referred to an altered condi- 
tion of the nervous centres. 

The movements of the tongue are sometimes deranged. A tre- 
mulous tongue is, in all acute diseases, of evil portent, but has no 
particular importance in chronic nervous disorders, such as hyste- 
ria, hypochondriasis, and chorea. If the patient prutrude his 



THE TONGUE. 259 

tongue very slowly, or leave it exposed after having shown it, it is 
a sign of great exhaustion, or of congestion or other pressure upon 
the brain. It occurs in all diseases of a typhoid type when the in- 
telligence becomes blunted. When the tongue is thrust constantly 
to one side, it indicates hemiplegia of the organ, and is owing, gene- 
rally, to disease of the opposite side of the brain. But the tongue 
often appears to deviate laterally when one corner of the mouth is 
retracted, owing sometimes to cerebral disease, and sometimes, as in 
old persons, to the loss of the teeth on one side. Imperfect or 
complete paralysis of the tongue impedes or prevents the articula- 
tion of sounds ; but the speech may be lost in some nervous affec- 
tions, or from sudden fright, without any loss of power in the lin- 
gual muscles. The writer has seen a pregnant female rendered quite 
speechless for several hours, by a loud clap of thunder. As she 
was recovering her power of articulation, she pronounced words 
with a slow, drawling, and hesitating utterance. 

Increased temperature of the tongue exists, and is very sensible 
to the patient in inflammation of the mouth and fauces, and in all 
fevers attended with a very hot skin. It is cool, or even cold, on 
the other hand, in Asiatic Cholera, sometimes in the cold stage of 
intermittents, and on the approach of death when the struggle is 
prolonged. 

The tongue may be enlarged in glossitis, and from cancer, and 
in the former to such an extent that it projects beyond the lips. 
This condition used frequently to result form excessive salivation. 
The tongue is also swollen in sore throat, and is large and flabby 
in many bad cases of dyspepsia, showing upon its edges indenta- 
tions made by the pressure of the teeth. Its entire volume may 
be diminished^ when there is great general emaciation ; if its 
size diminish very much, and it is at the same time retracted 
and pointed, even in acute diseases, the prognosis is bad. Pro- 
longed hemiplegia frequently induces atrophy of one side of this 
organ. 

In acute febrile disorders, moisture of the tongue is a favourable 
sign ; but dryness, especially when extreme, and accompanied with 
a fuliginous coating upon the teeth, augurs badly. This latter 
state is observed in all protracted fevers, whether symptomatic or 
idiopathic, and seems to be in direct proportion to the duration o( 



260 SEMEIOLOGY. 

the disease. Its higher degrees are combined with roughness, a 
fissured appearance, and a brown or even black colour of the in- 
vesting crust, and occurs ordinarily in affections of the typhoid 
form. It must not be confounded with a somewhat analogous 
condition in persons who sleep with the mouth open. The rough, 
enlarged, and deeply-fissured, but moist tongue, is of most com- 
mon occurrence in gastro-hepatic derangements. 

The tongue is pale whenever the blood has lost its normal pro- 
portion of red globules, as in hemorrhage and chlorosis, in chronic 
inflammation also of the intestinal canal, unattended with much 
fever. A bright red colour of the tongue is found in all violent 
inflammations, but especially in those of the upper portion of the 
digestive tube. Sometimes, as in scarlatina, the redness is not 
uniform, but shows itself in disseminated points, which are the tur- 
gid papillae, projecting through a white coating of mucus; or this 
colour may be confined to the sides and tip of the organ, while its 
centre is whitish. A moderate coating, whether white or yellowish, 
has generally been supposed to indicate the accumulation of mu- 
cous or bilious matters in the stomach, and a red, dry, and glazed 
tongue, chronic inflammation of the intestinal canal. But these 
signs, as well as most of those derived from the presence, or the 
peculiar characters of the coating, are very fallacious. M. Louis 
found that redness of the tongue existed with equal frequency in 
phthisical patients who had no lesion of the stomach, and in those 
of them in whom this organ was extensively diseased. A similar 
result was arrived at by this author in regard to the state of the 
tongue in typhoid (ever. 

The gradual disappearance of the coating from the circumference 
towards the centre of the tongue, is a favourable sign, and, in acute 
diseases, marks the commencement of convalescence. This pro- 
cess is sometimes arrested, and the tongue becomes dry and red 
upon the occurrence of some inflammatory complication, but the 
change may also depend upon too great strictness of the patient's 
diet, for the more favourable condition has often been found to 
return upon the cautious administration of more nutritious food. 
The tongue, like other parts within the mouth, may become the 
seat of membranous formations ; whenever this occurs as a com- 



SALIVATION DEGLUTITION. 261 

plication, either in acute or chronic disorders, and along with great 
exhaustion, it is a most unfavourable sign. Ulcers of the various 
sorts above described, aphthee, and the pustules of small-pox, are 
also met with upon the tongue. 

The saliva is diminished in most febrile affections, but is gene- 
rally increased when any of the parts within the mouth or fauces 
are inflamed or irritated, as in dentition, glossitis, tonsillitis, &c. 
Its profuse discharge is called ptyalism^ and is more marked when 
produced by mercury than by any other cause. Arsenic and 
iodine may also occasion it. It occurs after the use of emetics, in 
many cases of dyspepsia, and is a most annoying symptom of the 
disorder which sometimes attends pregnancy. It sometimes exists 
as an independent disorder, sialorrhea. Salivation is commonly 
observed in confluent small-pox ; it is regarded as a favourable 
sign, and its suppression as indicating peculiar danger. But if it 
depends, as it probably does, upon variolous pustules in the mouth, 
their condition must furnish more important indications than the 
mere quantity and duration of the discharge which they produce. 

The quality of the saliva doubtless excites many of the morbid 
gustatory sensations which have been noticed, particularly the acid 
taste. The saliva has been found to be acid in acute rheumatism, 
in dyspepsia, accompanied with pyrosis, in gastric inflammation, 
and in most instances of mercurial ptyalism. In some cases, 
however, of the latter affection it is distinctly alkaline, and in 
others retains its normal neutrality. 

Signs from Swallowing. — The morbid states of deglutition may 
be referred to one of two sets of causes, the one purely mechanical, 
the other depending upon diseased innervation of the oesophagus. 
In the first class may be arranged inflammation of the tongue, 
fauces, and oesophagus ; polypi, or other tumours in the pharynx, 
induration and softening of the gullet, foreign bodies or strictures 
within, and tumours, such as abscesses and aneurisms external to 
this tube, and scirrhus of the cardiac orifice of the stomach. To 
the second class belong compression, inflammation, and softening 
of the brain and upper portion of the spinal cord; hysteria, hydro- 
phobia, tetanus, and low fevers. 

It might be supposed that liquids would in all cases bo more 



262 SEM BIOLOGY. 

easily swallowed than solids. But this is not the case. When the 
throat is swollen and tender, liquids, which require a more com- 
plete contraction of the muscles of deglutition than solids, to propel 
them towards the stomach, necessarily excite more pain than soft 
solids ; so that the former are often rejected violently, when the 
latter move with less difficulty to their destination. In feebleness 
and partial paralysis of the oesophagus, also, the muscular fibres 
are more readily stimulated to contraction by a body offering a 
certain degree of resistance than by a liquid. In complete para- 
lysis, however, liquids descend the throat by the force of gravity, 
and therefore more readily than solids ; as they enter the stomach, 
they are apt to produce a rumbling noise, which, under the circum- 
stances, is an almost fatal sign. 

If merely imitating the act of swallowing give pain, there is in- 
flammation of the fauces. This act performed involuntarily, and 
without pain, is commonly owing to elongation of the uvula, which 
irritates the pharynx, and causes contraction of its muscles. If 
there is a sensation as of a ball in the throat, with general spasms, 
the difficulty is hysterical ; if, a short time after being swallowed, 
the food is regurgitated, cancer of the stomach must be suspected, or 
some cause mechanically compressing the oesophagus ; if cough 
attend every effort at swallowing, we may conclude that the epi- 
glottis or the edge of the laryngeal orifice is ulcerated; if the mere 
contact of a liquid with the mouth, or the sight of it, cause such 
spasms of the throat as to render swallowing impossible, and the 
patient have previously been bitten by an animal, the case is one 
of hydrophobia. When there is a loss of substance in the velum 
palati, the food is sometimes thrown into the nostrils. Food and 
drink are said, in popular phrase, " to go the wrong way," when 
they get into the larynx or trachea. This is apt to occur when 
the epiglottis is wholly or partially destroyed ; when there exists a 
fistulous communication between the oesophagus and trachea; it 
often takes place on attempting to swallow while laughing or talk- 
ing ; and is observed in the last stages of many diseases, when it 
depends upon insensibility. or paralysis of the muscles of the pha- 
rynx and larynx. Difficulty of deglutition is the more unfavour- 
able the longer it lasts, and, in general, less dangerous when it 



THE APPETITE. 263 

occurs suddenly, than when it comes on gradually ; for in the 
latter case it must be owing to organic disease involving the oeso- 
phagus or the brain, but in the former it is much more likely to 
depend upon inflammation, upon obstruction by a foreign body, or 
upon nervous disturbance. 

Signs from the appetite. — Thirst, or a desire for drink, is one 
of the most ordinary symptoms of febrile disorders, and its sudden 
increase in the course of chronic diseases may serve to reveal the 
occurrence of inflammatory complications. It is most intense 
during inflammation of the stomach or bowels, and when profuse 
discharges have taken place, as in diabetes, Asiatic cholera, and 
colliquative sweating. Apparent absence of thirst is frequently 
observed in ataxic fever, when, although the patient's tongue and 
mouth are as dry as a potsherd, his comatose state renders him 
insensible to their condition. 

The appetite for food is variously altered in disease. It is di- 
minished, in many cases, by the remedies administered. Opiates, 
and the prolonged use of a diluent or farinaceous diet, have this 
effect. Indifference to taking food, or anorexia, as was previously 
stated, is one of the first premonitory symptoms of acute disorders, 
and is a favourable sign, inasmuch as it appears to be a provision 
of nature for preventing undue excitement of the system. On the 
approach of convalescence, however, when the strength needs re- 
cruiting, it indicates an imperfect or a tardy recovery. At this 
period the return of the natural appetite augurs well, provided it is 
accompanied with a corresponding activity of nutrition ; but if this 
do not occur, there is reason to apprehend the development of or- 
ganic disease, especially phthisis, and the more so if the acute 
affection was pneumonia, or typhoid fever. 

Aversion to food occurs in nearly the same circumstances as 
anorexia, and is only an active phase of the same feeling. It is 
sometimes so strongly marked that the odour of the kitchen, or even 
the bare idea of eating, excites heaving of the stomach and disgust. 
In chronic disorders it is a very unfavourable symptom. It is 
common in pregnancy, and after the use of emetics. 

Voracious appetite, or bulimia, (/3ou, aug. and Xj/ao£, hunger) is 



264 SEMEIOLOGY. 

most frequently met with in nervous disorders, such as mania, hy- 
pochondria, and hysteria. The most extraordinary instances of it 
have been presented by persons whose intestinal canal was, like 
that of carnivorous animals, short and straight. A young Esqui- 
maux is mentioned by Captain Parry, who devoured, in twenty-four 
hours no less than " 35 lbs. of various kinds of aliment, including 
tallow candles." Insatiable hunger is very apt to exist during 
convalescence from acute diseases in which the stomach or bowels 
have been inflamed, and it cannot be gratified without great danger. 
In the progress of recovery from typhoid fever it is often observed, 
and in many cases of this malady which terminate fatally, from 
perforation of the intestine, the result is owing to a too early or 
undue indulgence in animal food. The writer witnessed a case of 
sudden death, during convalescence from typhoid fever, in a patient 
who perished while greedily devouring a bowl of soup. A piece 
of gristly meat, larger than a pigeon's egg; was found tightly 
wedged in his larynx. 

Nausea, (" from volvz, a ship, because those unaccustomed to 
sailing are affected with the sensation,") is a desire to vomit. It 
may arise from merely nervous disorder, from sympathy of the 
stomach with some other organ, or from disease of the stomach 
itself. It has no particular significance in disease except as a pre- 
cursor of vomiting. It is one of the earliest and most constant 
signs of pregnancy. 

Eructation, or the discharge of flatus from the stomach, and 
regurgitation or the rising of the solid or fluid contents of this or- 
gan into the throat, although in their result somewhat akin to vomit- 
ing, differ from it in being unattended with nausea, and in being 
effected by the action of the stomach and oesophagus alone. They 
are usually accompanied with heart-burn (pyrosis) in dyspepsia, 
and the fluid which rises is pungent, hot, and very sour. At other 
times it is insipid, or slightly saltish, and is then called water- 
brash ; to this form of eructation habitual drunkards are very sub- 
ject. Regurgitation of food along with the gastric fluids is less 
frequent, and generally indicates more serious disorder, than the 
form just noticed. It occurs in some of the worst cases of dys- 
pepsia, and in cancer of the stomach. The odour of the several 



VOMITING. 265 

substances rejected is various. They may be inodorous, or have 
the smell of sulphuretted hydrogen, or a rancid smell, or that of the 
food lately taken, as of cabbage, garlic, &c. Eructation of wind 
usually affords relief to a sense of oppression at the pit of the sto- 
mach ; in some attacks of indigestion, gas is extricated in enormous 
quantities. Regurgitation of solids and liquids is an annoyance 
without corresponding advantage. 

Vomiting may be symptomatic of a local affection of the stomach, 
or of disorder in some other part of the system. Its simplest form 
is that excited by the presence of undigested food in the stomach. 
It is then preceded by loathing, nausea, chilliness, watering of the 
mouth, paleness, coldness of the extremities, and a slow or small 
pulse. Heaving of the abdomen then takes place, and by the con- 
currence of the muscles of its parietes, those of the stomach, and 
the diaphragm, the contents of the stomach are rejected. A marked 
sense of relief follows this operation, the pulse becomes fuller and 
softer, and the skin warm and moist. But, when vomiting is ex- 
cited by any other cause than that just mentioned, the evacuation 
of the stomach is not followed by so great relief; as when the 
mucous lining of this organ has been directly irritated, or is in- 
flamed, or when the sympathetic cause is permanent, as in pregnan- 
cy. It is then painful and exhausting, often exciting cramps in the 
stomach, or, as in peritonitis, producing the most intolerable suf- 
fering. By the violent retching and straining which sometimes 
accompany this act, it becomes a cause of abortion in pregnant fe- 
males, of hernia, ofapoplexy, of the rupture of an aneurismal tumour 
or of some abdominal organ, or may cause the involuntary expul- 
sion of the faeces and urine. In most acute diseases it occurs but 
once or twice, and that at the period of invasion, in others such as 
cholera morbus, peritonitis, hernia, dec, it may continue through- 
out the attack. It is sometimes brought on, particularly after eat- 
ing, by violent coughing, as in phthisis and hooping-cough. Chil- 
dren vomit more easily than adults, old persons rarely do so spon- 
taneously, and always with much suffering, and great risk of 
rupturing the heart and arteries. 

Vomiting is always more favourable at the commencement of 
diseases seated either in the brain or stomach, than when it 

23 



266 SEMEIOLOGY. 

takes place for the first time at a more advanced stage. The re- 
lief afforded by it is a fair criterion of its probable influence upon 
the course of the attack. If the epigastric uneasiness subside, the 
skin become moist, and the nausea disappear, the influence of the 
vomiting is likely to be salutary ; but if nausea, epigastric sore- 
ness, and general distress persist, there is reason to fear some du- 
rable alteration of the stomach. Vomiting may, however, become 
literally chronic; in that case its repetition is not quite so unfa- 
vourable as in the case just recited, provided there be no evidence 
of organic disease of the stomach or its subsidiary viscera ; for it 
then probably depends upon nervous disturbance of the stomach, 
or upon thickening or attenuation of the mucous membrane of this 
organ. 

Some notion of the nature of a gastric disorder may be deduced 
from the tolerance or rejection of certain kinds of food and medi- 
cine. Those of a stimulant and tonic kind never fail to aggravate 
vomiting produced by inflammation of the stomach, while they more 
commonly allay this symptom if it depends upon nervous derange- 
ment. 

The sooner vomiting takes place after eating the higher up in the 
digestive canal is the disease producing it. If directly after a meal, 
it may either indicate chronic gastritis, or cancer of the vicinity of 
thecardia, or general thickening of the walls of the stomach with 
contraction of the cavity ; if it do not come on until ten or 
twelve hours after eating, and the matters thrown up consist of the 
food taken so long before, cancer of the pylorus, or dilatation of 
the stomach is indicated. 

It is important to ascertain the quality of the matters vomited, 
for they vary with the morbid condition present. They consist 
1st, of more or less perfectly digested food, as in the stage of in- 
vasion of most acute diseases ; or 2d, of mucus, as in pregnancy 
and gastralgia ; 3d, of a serous fluid containing white flocculi, as 
in Asiatic cholera ; 4th, of blood, in gastric and oesophageal hae- 
morrhage, or when this fluid has been exhaled from the air-pas- 
sages or the mucous cavities of the head ; 5th, of bile, in the various 
forms of remittent and bilious fever and hepatitis, in protracted 
dyspepsia, and in most cases where the act of vomiting is accom- 



MATTERS VOMITED DEFECATION. v 267 

panied with severe straining ; 6th, of stercoraceous matter, in stran- 
gulated hernia, intussusception, and other obstructions of the in- 
testine ; 7th of pus, when an abscess, (usually of the liver,) opens 
into the stomach ; 8th, of a matter resembling coffee-grounds, and 
which is most probably blood which has been acted upon, at the 
moment of its exhalation, by the acids of the stomach. This sub- 
stance is very generally vomited in fatal cases of yellow fever ; it 
is also observed among the matters rejected in cancer of the sto- 
mach, when the cancerous deposit is formed near the pylorus, and 
its inner surface has become ulcerated ; 9th, of lumbrici, hyda- 
tids, or gall-stones ; but of these, the two latter are very unusual ; 
10th, of substances which have been swallowed, and act as irri- 
tants, or otherwise excite vomiting; such are all the acrid and nar- 
cotic poisons. The matters vomited, in any case where the cause 
of the attack is obscure, should always be preserved for examina- 
tion ; for they may lead to the discovery of a suicidal intention on 
the part of the patient, or of a felonious intent on that of some 
concealed enemy. Finally, vomiting may be excited by the pre- 
sence of false membranes in the throat, or be induced, artificially, 
in croup, in both of which cases fragments of fibrin may be found 
amongst the contents of the basin. 

The small and large intestines offer but few symptoms which have 
not already been noticed under other heads. Allusion has been 
made to the development of gas which frequently takes place in 
them, producing oppression, and colics. Its movement, from place 
to place, when mingled wijh liquids, gives rise to certain gurgling 
or rumbling sounds, called horborygmi. They are of little value 
as signs, except in typhoid fever, when pressure appropriately 
made over the region of the ileo-coecal valve causes a distinct gur- 
gling, which thus limited is almost peculiar to the disease in ques- 
tion. In doubtful cases of this affection it becomes, therefore, a 
diagnostic sign of some consequence. 

Signs from defalcation. — Unnatural frequency of the stools, or 
diarrhoea, and their great infrequency, or constipation, are two of 
the most uniform accompaniments of disease. These terms are 
sometimes applied to denote the consistence of the alvine evacua- 
tions, without regard to their frequency, the former to those of less, 



268 SEMEIOLOGS. 

and the latter to those of more, than usual consistence. But, as 
a general rule, frequent discharges are more or less liquid, and the 
infrequent rather hard. Even in healthy subjects, the number of 
daily evacuations is subject to much variety. Infants have three, 
four, or five passages in the twenty-four hours, adults usually but 
one, and the aged even less. Those who lead a sedentary life, 
especially if they eat freely of stimulating food, go to stool very 
rarely, often not more than once in from three to six days. This 
confined habit of body prevails amongst females, particularly mil- 
liners, dress-makers, and others who sit constantly, and eat irregu- 
lar meals. In them constipation leads to other diseases, and is 
frequently associated with a chlorotic condition, and with neural- 
gia, leucorrhosa, sick headache, and other evidences of ill health. 

The use of opium, lead, and astringent medicines, generally, 
gives rise to constipation ; and it follows the action of many pur- 
gatives. It is nearly a constant symptom of insanity, and other 
nervous disorders, as well as of acute inflammation of the brain 
and its membranes, and of structural diseases of the upper part of 
the spinal cord. Whatever presents a mechanical impediment to 
the passage of fseces through the intestine, induces obstinate con- 
stipation ; as, for example, tumours, strictures, collections of scy- 
bala, and worms, as well as whatever prevents the intestinal 
muscles from maintaining the peristaltic action ; flatulent disten- 
tion, for instance, paralysis and peritonitis. 

Fever, from whatever cause arising, (inflammation of the intes- 
tine excepted,) diminishes the secretions.of the mucous membrane 
of this canal ; a fact which explains the occurrence of constipa- 
tion in all such affections, and the origin of the universal employ- 
ment of purgatives in their treatment. The existence of constipa- 
tion merely, except in so far as it leads to an excessive accumula- 
tion of fseces in the bowels, has but little influence upon prognosis; 
but this state acquires great importance when taken along with the 
symptoms which in certain cases accompany it. Thus, when it is 
attended with pain in the abdomen, and vomiting, obstruction of 
the bowels is indicated ; and its cessation, under these circum- 
stances, proves the obstruction to have been only temporary. It is 



CONSTIPATION DIARRIKEA. 269 

of unfavourable import, when obstinate, in acute affections of the 
brain. 

In diarrkcea, the stools are more frequent than natural, varying 
in number, from two or three to forty or fifty, in the twenty-four 
hours. It occurs incidentally in a great number of diseases, and 
habitually in inflammation of the intestinal mucous membrane, and 
when the latter is irritated by indigestible food, acrid substances, 
hardened fasces, &c. When it attends the commencement of an 
acute attack of a disease seated elsewhere than in the abdomen, it 
is of unfavourable significance; but if it arise later in the course 
of the complaint, and is followed by an alleviation of the symp- 
toms, it is sometimes critical. Thus, dropsies have been cured by 
spontaneous diarrhoea. On the other hand, in persons of the 
phlegmatic temperament, and in those who already present signs 
of scrofula or tubercles, the supervention and persistence of this 
symptom indicate the existence of tuberculous ulcerations of the 
intestine. It is also a bad omen, when, occurring in chronic dis- 
eases of any kind, it is followed by great debility. 

Sometimes there is an incessant and urgent desire to go to stool ; 
the patient complains of a sense of weight or bearing down about 
the anus, as if a large discharge were about to overcome his efforts 
to restrain it; and yet when he yields to the call, he either passes 
nothing, or, with scalding pain, a quantity in every way dispropor- 
tioned to the violence of his distress. This symptom, tenesmus, 
is characteristic of dysentery. It occurs, also, when the sensibility 
of the rectum is augmented by inflammation, piles, or ascarides ; 
and when irritated by the pressure of abscesses, vesical calculi, an 
enlarged prostate gland, a retroverted or gravid uterus, &c. In 
fissures of the anus, the scalding and tearing sensation is often so 
agonizing that patients dread even the thought of going to stool, 
although they know that the freces must grow harder, and their 
suffering be increased by the delay. 

When the sphincter ani has lost its power of contracting, through 
disease of the brain or spinal marrow, or through great debility, 
the fbcces are discharged involuntarily; in the one case without the 
patient's consciousness, and in the other without his being able to 
prevent it. In acute diseases, this symptom indicates almost cer- 

23* 



270 SEMEI0L0GY. 

tainly a fatal result ; but in chronic affections, idiocy and dementia, 
it involves no peculiar danger. Sometimes the involuntary dis- 
charge of fasces is consequent upon an unnatural opening being 
formed for their escape, as in artificial anus, caused by a wound 
of the abdomen, or hernia. M. Chomel relates an extraordinary 
case of a woman whose small intestine communicated directly with 
the cavity of the uterus, adhesions having been formed through the 
irritation of cancer in the latter organ ; in consequence of which 
abnormal arrangement, the faeces escaped continually from the 
vagina. They pass through the same canal in that most disgust- 
ing affection, recto-vaginal fistula. 

The inspection of the divine evacuations is of great utility in 
practical medicine. It is too much the habit, at present, to omit 
their examination altogether, on account of its repulsiveness, and 
the difficulty of effecting it, either in private or public practice ; 
and this habit has induced the still more blameable one, of neglect- 
ing to make proper inquiries on the subject. 

The consistence of the fasces varies in the healthy state accord- 
ing to the age, the food used, the habits of exercise, &c. Children 
at the breast pass fasces of pap-like consistence. Subsequently, 
with advance of years, the fasces grow progressively harder. Vege- 
table furnishes softer discharges than animal food. In disease, the 
excrement may be as hard as dry clay, or as thin as serum, or of 
any degree of consistence between these two extremes. It is most 
liquid in mucous and serous diarrhoeas, and hardest when a me- 
chanical impediment to the passage of the contents of the intestines 
exists. In mania, melancholy, and lead colic, the fasces are ex- 
tremely compact. When long retained, they are apt to be dis- 
charged in firm, globular masses, resembling sheep's or goat's dung. 
If they are then unmixed with fluid, it may be inferred that the 
bowels are completely evacuated ; but when thus mixed, it is pro- 
bable that a hardened mass is retained somewhere in the colon, 
which, by its irritation, causes this combination of the discharges 
proper to both diarrhoea and constipation. Persons of sedentary 
habits frequently assert their bowels to be perfectly regular, and 
even loose, when they have in reality a large collection of scybala 
in the colon, exciting a daily evacuation like that described. In 



THE F.ECES. 271 

stricture of the rectum, the faeces assume the shape and size of the 
aperture through which they pass, and may be flattened, indented, 
or long and slender. 

The aggregate quantity of intestinal evacuations is, for the most 
part, small in constipation, and large in diarrhoea ; but the indi- 
vidual stools are more commonly copious in the former. It has 
already been stated that they are both scanty and frequent in 
dysentery. 

The colour of the fseces varies considerably. In children at the 
breast, they are. habitually of a light yellow colour; during the 
first dentition, and especially in the summer complaint (gastro- 
enteritis) of this climate, they often resemble hashed spinach, both 
in colour and consistence. This colour, frequently, does not show 
itself until the excrement has been exposed to the air for several 
hours — a fact which accords with the opinion of several eminent 
chemists, that the colour is not derived from the presence of bile, 
but of a salt of iron. In malignant cholera the stools contain 
little flakes of fibrin, which gives them a turbid white appearance, 
resembling rice-water. Under all circumstances in which the se- 
cretion of bile is deficient, they are of a grayish-white colour, like 
that of putty or potter's clay ; when bile is in excess, they acquire 
a brownish yellow, or even a dark bronze colour. Pale-coloured 
stools do not necessarily depend upon a scanty secretion of bile. 
They are often produced by the continued use of chalk mixture. 
Pure bile is sometimes found in f he fasces of persons lately re- 
turned from a hot climate; after a violent fit of anger, and after 
purgative doses of calomel. Redness of the evacuations is gene- 
rally due to the presence of blood, and is always a sign either of 
hyperemia, passive congestion, or the loss of the fibrinous element 
of the blood — those cases only excepted in which this fluid has 
been swallowed, or proceeds from the rupture of an aneurismal 
sac, or from a wound. Thus, it is discharged from the bowels in 
dysentery, in congestion of the liver and spleen, in hemorrhoids, 
in petechial typhus, in scurvy, and purpura. Bloody stools occur, 
also, in cancer of the intestine; the abdominal pain, constipation, 
general emaciation, and a tumour of the abdomen, serve to distin- 
guish this from other occasions of intestinal hemorrhage. Hsemor- 



272 SEMEIOLOGY. 

rhoidal flux may be recognised by the purity of the blood lost, the 
absence of colicky pain, the presence of a feeling of weight in the 
sacral region, and the sense of relief which follows the discharge. 
In general, blood from the upper portion of the digestive tube is 
darker than what is exhaled nearer to the anus. When intimately 
mixed with the faeces, it gives them a reddish-brown, or blackish 
hue. It should be remembered, however, that preparations of iron 
have the same effect. Rhubarb stains the fasces yellow, and indigo 
blue. A black substance may be evacuated by stool, different from 
any of the above. Dr. Graves mentions the case of a dyspeptic 
patient who discharged, by vomiting and purging, enormous quan- 
tities of a black fluid which exhaled an insupportable odour of sul- 
phuretted hydrogen. When the gas just named is present in the 
bowels of a person under the use of acetate of lead, the dejections 
are turned black. 

Sometimes half-digested food is discharged from the bowels. 
This state is called lientery. It is a sign of weak digestion, or of 
chronic inflammation of the intestinal tube. It is not uncommon in 
tuberculosis of the mesenteric glands. Infants at the breast fre- 
quently void curded milk ; this may arise from a state of over-ac- 
tivity of the digestive canal, causing the food to be hurried on loo 
rapidly; but it is also quite consistent with good health, and then 
arises from the child having swallowed more milk than it was able 
to digest. 

Serous stools have been alluded to as they occur in cholera ; 
they may also follow the suppression of copious discharges from 
other organs, and the use of saline and drastic purgatives. Spon- 
taneous serous fluxes depend immediately upon passive congestion 
of the abdominal organs. Evacuations of mucus accompany en- 
teritis, and the first stage of dysentery ; they are often met with 
when worms, or hardened fasces accumulate in the bowels. Pus, 
when found in the dejections in considerable quantities, and but 
partially mixed with fasces, may be inferred to proceed from the 
opening of an abscess into the intestine ; when it only streaks the 
surface of moulded fasces, its source is a fissure or fistula about the 
verge of the anus. In dysentery it is sometimes mingled with 
blood, and shreds of false membrane. The last-mentioned sub- 



THE F.ECES. 273 

stance is occasionally passed in the form of a complete tube, du- 
ring the enteric inflammations of children. Fragments of concrete 
lymph in the dejections, have been mistaken for joints of the tape 
worm, and give both patient and physician unnecessary alarm. A 
close inspection with the aid of a magnifying glass, will readily 
detect the absence of regular structure in the former. Portions of 
the intestine separated by sloughing after intussusception may be 
thrown off by stool, and still the patient recover. Biliary and in- 
testinal calculi, and, when a fistulous communication between the 
bladder and rectum exists, urine also, may be found in the stools. 
The discharge of worms is important as being the only infallible 
sign of the existenee of these parasites within the intestinal canal ; 
all the other so-called symptoms of worms, when taken together, 
furnish only a probability of their presence. 

The natural odour of the faeces is sufficiently offensive, but in 
some cases of disease it becomes intolerably foetid. This is of 
course the case when the bowels are attacked with gangrene, 
whether from cancer, stricture, or follicular or mucous ulceration ; 
in simple ulceration, in almost all affections of a typhoid form, when- 
ever the contents of the bowels are long retained, as in melancholy, 
in old age, from neglect of defsecation, &c, they are somewhat less, 
but still highly offensive. In all diseases attended with rapid wast- 
ing of the body their smell is intensely sickening. The stools of 
consumptive patients are of this description. Chemical analysis 
has shown that they contain a very large proportion of fat. It may 
be conjectured that the fatty liver of phthisis results from the ab- 
sorption of adipose matter from the intestine through the radicles 
of the portal veins. 



CHAPTER III. 

SIGNS FROM THE GENITO-URINARY APPARATUS. 

The male organs of generation furnish several useful signs. The 
penis is usually enlarged in children who are addicted to onanism, 
and in adults who indulge in venereal pleasures. If they carry them 
to great excess, on the other hand, the organ becomes shrunken 
and flaccid. Priapism in children may be owing to the vice just 
named, to vesical calculus, to ascarides in the rectum, or to the 
irritation of hardened fasces there. In youths and grown persons 
it is a favourable sign on the approach of convalescence, as show- 
ing the renewed activity of the nutritive function. When, on the 
contrary, it occurs during coma, or after injuries to the brain or 
spinal marrow, it is a sign of evil augury. When it attends af- 
fections of the bladder or urethra, it shows them to be unusually 
active. Priapism is one of the symptoms of erotic mania, or 
satyriasis ; its importance then is secondary to that of the primary 
affection. It may also proceed from prolonged continence, in per- 
sons of a nervo-sanguineous temperament, and from an over-dose 
of cantharides. An habitually flaccid state of the penis is observed 
in impotence depending upon a want of venereal desire ; this is 
produced by several diseases, but in a marked degree by diabetes, 
Greek elephantiasis, and chronic diseases of the brain. Involun- 
tary seminal emissions, upon slight provocation, proceed from de- 
bility and generally from that induced by venereal excesses or 
onanism. 

The scrotum and testicles may be the seat of swelling of various 
kinds. Anasarca is known by its occupying the whole scrotum, 
and its coinciding with subcutaneous effusion in other parts. 
Swelling of one side may be owing to distension of the cavity of 
the tunica vaginalis. This may be due to hydrocele, or hernia, 



ORGANS OF GENERATION. 275 

affections which are chiefly distinguished by the transparency of 
the former, and the opacity of the latter tumour. A tumour com- 
posed of tortuous and soft veins, and diminishing in the horizontal 
position, is formed of the enlarged veins of the cord, and called 
varicocele. Simple enlargement of the testis occurs in the metas- 
tasis of mumps. The diagnosis of other tumours of the testicle is 
very difficult, but very important, and belongs to the province of 
special surgical pathology. Retraction of the testicle is observed 
during a fit of the gravel. Excruciating pain in this organ, with- 
out change of form, size, or temperature, is characteristic of the 
complaint described by Sir Astley Cooper as irritable testis, and 
which subsequent investigations have shown to be, essentially, 
neuralgia of the ileo-scrotal nerve. 

The female parts of generation are of far greater consequence 
than the male, in semeiology. Their close sympathetic relations 
with almost every other part of the organism, cause them to share 
in nearly every disease which can affect the economy, and their 
own disorders become a prolific source of mischief to the gene- 
ral health. 

Morbid discharges from the vagina are of several kinds ; — that 
of gonorrhoea, which is yellowish or greenish, and accompanied 
with heat, tenderness, and swelling of the parts; that of leucorrhcea, 
which is generally of a lighter colour and muco-purulent, but some- 
times is not distinguishable from the last mentioned ; that of can- 
cerous degeneration, which is sanious, bloody, and extremely 
foetid ; and that of the lochia, which follows parturition, is at first 
bloody, and gradually becomes like healthy mucus, and exhales a 
stale and disagreeable smell. Leucorrhcea is a term usually ap- 
plied to all chronic discharges from the vagina, and may depend 
upon various causes. Amongst these are inflammation of the 
vagina and lining membrane of the uterus, indurations, polypi, 
steatomatous tumours, scirrhus of the vagina or womb, displace- 
ment of the uterus, and the irritation of oxyures in the rectum, 
hardened foeces in this canal, and stone in the bladder. It is also 
frequently associated with the plethora produced by over-feeding 
and sedentary habits, and, on the other hand, with more direct de- 
bility, as in chlorosis, prolonged lactation, &c. The difficulty of 



276 SEMEIOLOGY. 

ascertaining the real cause of fluor albus in a given case, renders 
necessary the employment of the touch and the speculum, in order 
to obtain a satisfactory notion of its origin. 

The suppression of the lochia is usually regarded as the cause 
of the inflammatory affections of the womb and peritoneum which 
so frequently and with such fatality succeed it ; but it is now suffi- 
ciently proven that such suppression is the consequence, and not 
the cause, of these dangerous incidents ; they begin to show them- 
selves before it commences. 

Sterility is sometimes, though rarely, owing to mechanical im- 
pediments to the passage of the semen through the vagina, uterus, 
or fallopian tubes ; it is very commonly associated with amenor- 
rhcea, but is frequently observed in cases where neither of these 
causes, nor any others, can fairly be alleged. 

The menses are disordered in many different diseases. They 
may be scanty or suppressed ; they may be accompanied with 
various degrees of pain ; or they may be too profuse. It is not easy 
to generalize the circumstances under which these several condi- 
tions exist. In regard, however, to scanty catamenia it may be 
admitted, that, apart from their frequent dependence upon struc- 
tural lesions of the ovaries and womb, they indicate a deteriorated 
condition of the nutritive function, as may be inferred from the 
partial or complete suspension of the menstrual flow in chronic 
exhausting maladies, and especially in pulmonary consumption. 
In the case of a female predisposed to this disease, the state in 
question should excite alarm. The fact is familiar to every one, 
that suspended menstruation is one of the most ordinary of the 
signs of pregnancy. 

Signs from the Urine. — With a return to the study of nature 
on the part of modern physicians, the habit of examining the 
urine, so prevalent amongst the ancients, has been revived. For- 
merly, the signs derived from this source were interpreted in the 
loosest possible manner, and used to illustrate the most opposite 
hypotheses. Now, the medical profession appears too much dis- 
posed to adopt the results of chemical investigation as final, and to 
apply them on all occasions to explain the phenomena of disease. 
The latter error has thus far proved to be the less dangerous one ,• 



HEALTHY URINE. 277 

yet it must be guarded against, for unless the theories which are 
now beginning to display their brilliant coruscations around the 
scanty and unaffiliated facts of pathological chemistry differ 
greatly from all that have dazzled scientific men during the last 
two thousand years, the)'' will soon disappear and be forgotten. 
While, therefore, it is necessary to present a succinct account of 
the pathological indications furnished by the urine, so far as there 
seems to be sufficient evidence of their reality, we shall not burden 
the description with those numerous details, which are either un- 
important in the present connexion, or still continue to be subjects 
of dispute. 

Healthy urine, when recently discharged, possesses the ordinary 
temperature of the body, is transparent, of a lemon or amber 
colour, exhales a peculiar aromatic odour, which it loses on cool- 
ing, but regains on being warmed, and has a bitter, saline, and 
somewhat pungent taste. Its average specific gravity is about 
1*018. It has a slightly acid reaction. About ninety-three parts 
in one hundred of such urine are pure water; the remainder are 
made up chiefly of urea, and saline and organic matters, which 
constitute from six to seven hundredths of the whole amount of 
urine discharged. It is estimated that about two and a half ounces, 
avoirdupois, of solid matter are eliminated by the kidneys of a 
healthy adult in twenty-four hours, of which nearly one-half is 
composed of urea, a substance formed from the effete nitrogenized 
products of nutrition. 

The quantity of urine voided varies greatly even in health, and 
in different individuals ; but, other things being equal, depends upon 
the amount of fluid ingested. It is more copious in winter than in 
summer. In the latter season, much more water is consumed, but 
its tendency is to the skin, where it serves the purpose of keeping- 
down the temperature of the body by its evaporation. In winter, 
on the other hand, there is little or no sensible perspiration, and 
the fluids of the economy are excreted chiefly through the kidneys. 
The watery element of the urine is alone influenced in its amount 
by the activity of the other secretions; so long as health continues 
the daily average of the solid constituents remains very nearly the 
same. Hence it is evident that the sp. gr. of the urine must be 

24 



278 SEMIOLOGY. 

low when this fluid contains much water, and high when its pro- 
portion of water is small. 

But the specific gravity, or the proportion of solid contents in the 
urine, is not the same at all hours. After copious draughts of 
water, its sp. gr. is lowest, (1*003 to 1*009),* what is voided on 
rising in the morning, if no supper have been eaten the night be- 
fore, is formed almost exclusively from the waste of the body, and 
its sp. gr. ranges from 1*015 to 1*025,* the urine secreted during 
the digestion of a hearty meal is loaded with solid matters, and its 
sp. gr. is from 1*020 to 1*030. Hence the average specific gravity 
of the urine can only be ascertained in a particular case, by adding 
together and examining all that is passed during the twenty- 
four hours. If this is impracticable, a near approach to the truth 
may be made by determining the sp. gr. of that voided before 
breakfast. 

Besides these periodical changes, there are others due to the 
quality of the food. Animal food, containing a large proportion of 
nitrogen, renders the urine heavier; vegetable food, by means of 
its watery constituents, lowers the density of the urine. From 
these considerations it is evidently easy to calculate how much 
solid matter is daily voided in a given case, merely by knowing the 
sp. gr. of the urine containing it. For if 1000 grains of urine of a 
certain sp. gr. contain so many grains of solid matter, a given 
weight of urine of any other sp. gr. must contain a proportionate 
weight of solids. Tables have been constructed upon this principle 
which show at a glance the quantity of solids in 1000 grains of 
urine of different densities ; so that we have only to learn the ab- 
solute weight and the sp. gr. of the urine passed by an individual 
in twenty-four hours, in order to determine the weight of solid 
matter excreted by his kidneys during this period. 

The most important solid constituents of normal urine, and which 
undergo extensive changes in disease, are the following. Urea, of 
which rather more than half an ounce is said to be secreted in 
twenty-four hours : Uric acid, of which about eight grains are 
passed daily, in combination with ammonia, forming a soluble 
urate. But when the ammonia is withdrawn, or is insufficient to 
saturate the uric acid, this latter is precipitated in a solid form, 



CHANGES IN HEALTHY URINE. 279 

constituting red gravel, and the most ordinary variety of calculus. 
There are several fixed salts including the sulphate of potash, the 
phosphates of soda and lime, and the ammonio-phosphates of soda 
and magnesia, of which, taken together, about 138 grains are con- 
tained in the urine evacuated during twenty-four hours. 

So long as the above-mentioned constituents maintain their 
normal relations to one another, and to the quantity of urine dis- 
charged, the fluid remains clear and transparent for some time after 
it has become cool, or is perhaps rendered a little hazy by float- 
ing mucus. After a time, however, an unpleasant odour is exhaled, 
the urine has become alkaline, a precipitate of the triple phosphate, 
and of the phosphate of lime is thrown down, and a greasy iride- 
scent scum composed of these salts, and of mucus, forms upon the 
surface of the liquid. The addition of hydrochloric acid causes 
such urine to effervesce by decomposing its carbonate of ammonia. 
These, and similar conditions, found in urine after a sufficient time 
has elapsed for the decompositions noticed to take place sponta- 
neously, are not, therefore, to be regarded as indicative of disease. 
In like manner certain modifications of its physical properties 
are quite consistent with health, and may be produced at will- 
Madder imparts a deep orange-colour to the urine, infusion of log- 
wood, raspberries, mulberries, and blackberries, increase its red- 
ness ; indigo makes it blue, rhubarb and angustura bark yellow, 
and ferruginous preparations blackish. Turpentine communicates 
to it an odour compared to that of violets ; copaiva its peculiar 
smell, and asparagus a disgusting stench. Tannin taken internally 
is excreted by the kidneys, and causes a black precipitate to be 
formed when a solution of a salt of iron is added to the urine- 
Mineral acids received into the stomach do not affect the composition 
of the urine, but vegetable acids and alkalies, respectively commu- 
nicate to it their properties. 

The physical qualities of morbid urine. — The qua?itity of the 
urine is much influenced by disease. When this fluid ceases to be 
secreted by the kidneys, there is said to be sitppressio?/,, and when 
it cannot escape from the ureters or bladder, retention of urine. 
The former may depend upon inflammation of the kidneys them- 
selves ; it is rarely, however, complete. Extreme scantiness of the 



280 SEMEIOLOGY. 

urine is met with chiefly in low fevers ; but, under whatever cir- 
cumstances it occurs, it is an almost fatal sign. A more moderate 
diminution of the urinary discharge accompanies nearly all febrile 
affections even from their commencement; during the decline of 
scarlatina, and other exanthemata, the continuance of this condition 
is unfavourable, for it portends dropsical effusions. Retention of 
urine (which is distinguished from suppression by the existence of 
a rounded tumour formed by the distended bladder in the hypogas- 
trium) may result from a mechanical impediment to the escape of 
the urine, such as a calculus in the urethra or bladder, stricture, 
enlarged prostate, the pressure of the gravid uterus, of the displaced 
unimpregnated womb, or other tumour within or without the blad- 
der; or from a loss of the contractile power of the muscular coat 
of this organ, in consequence of congestion or other disorder of the 
brain or spinal marrow, or, finally, from spasm of the sphincter 
vesica). Retention is a common symptom in all affections attended 
with coma, and also in hysteria, and should in such diseases be 
carefully inquired after. The quantity of the urine is increased 
whenever the other secretions are diminished without fever, as in 
the cold stage of intermittents, and under the influence of fear, 
anxiety, and other depressing passions. It also exists as an inde- 
pendent disease, in which for many years the patient may pass 
gallons of normal but diluted urine during the day, and suffer no 
inconvenience beyond the thirst which prompts him to repair so 
great a waste. In diabetes there is a similar excessive flow of 
urine, but not of normal composition. Profuse discharges from the 
bladder occasionally occur as critical evacuations in dropsy. 

Urine may be quite colourless, and limpid as water, when its 
quantity is increased by any cause not affecting its composition ; 
as after copious draughts of aqueous fluids, in hysteria, &c. It 
may be rendered whitish or lactescent by the admixture of mucus, 
or pus, or the phosphatic salts ; of a dark-red colour by the pre- 
sence of dissolved blood, as in hemorrhage from the mucous lining 
of the urinary passages; of a bright or yellowish-red in inflamma- 
tory fever; and of a yellow or greenish hue in affections of the 
liver attended with jaundice. 

The odour of urine is frequently ammoniacal in low forms of 
fever, after injuries to the spinal cord, and even when from other 



QUANTITY, ODOUR, ETC., OF THE URINE. 281 

causes the secretion has been long retained in the bladder. It is 
often foetid when it contains pus derived from ulceration of the uri- 
nary mucous membrane, particularly when of a malignant form, 
and also in those diseases marked by dissolution of the blood. It 
has a sweetish smell and taste in diabetes. 

The consistence of the urine varies in disease. During the first 
stage of acute diseases, it is usually thin, but becomes turbid du- 
ring their decline ; when this change does not depend upon disease 
of the urinary apparatus itself, it is a favourable indication. Urine 
which is at all turbid when voided, deposits, on standing, a sedi- 
ment, whose composition it is very important to understand. Some- 
times it is formed of mucus, sometimes of pus, blood, or semen, or 
of some one or more of the saline, acid, or earthy constituents of 
the urine. Blood may usually be recognised by its colour: but, 
thus far, no method of clearly distinguishing in all cases between 
pus and mucus, without a microscopical examination, has been 
discovered. Often, however, the respective qualities of these two 
products are distinctly marked, to wit : the whitish, translucent, 
stringy, and tenacious characters of mucus, and the greenish 
colour, opacity, and slight adhesiveness of pus ; but in many in- 
stances the two products are commingled. The urinary sediment 
may also contain calculi, worms, hydatids, and, in reclo-vesical 
fistula, even fasces. A whitish, opalescent, and somewhat fatty 
pellicle called kystein, is formed upon the surface of the urine of a 
large proportion of pregnant females, and may therefore be ranked 
amongst the signs of pregnancy. 

Tfie chemical properties of morbid urine. — The constituents of 
the urine, whether normal or accidental, detected principally by 
chemical reagents, may now be summarily noticed. The patholo- 
gical conditions affecting the proportion of urea do not appear to 
have been well ascertained, nor to possess a high degree of impor- 
tance. In diabetes it is replaced by sugar. Uric acid is some- 
times present in large excess, and is then precipitated in the form 
of a crystalline deposit. It may, however, be thus precipitated 
without being redundant, for a stronger acid than itself, as the mu- 
riatic or phosphoric may accidentally exist in the urine, and uniting 
with the base of the urate of ammonia, cause the acid to be thrown 

24* 



282 SEMEIOLOGY. 

down. The earthy phosphates are less commonly in excess. But 
when they are so, their physical characters betray their presence. 
They are, in some instances, sufficiently abundant to render the 
urine milky when first passed. Not unfrequently they form dense 
masses in the urine, hanging in ropes like the thickest puriform 
mucus, from which, indeed, they cannot be distinguished by the 
naked eye. Sometimes, as the urine cools, they are deposited in 
the form of a white crystalline gravel ; or, as more commonly 
happens, after a few hours repose of the liquid, crystals of these 
salts collect upon its surface in the form of an iridescent pellicle, like 
the film which is seen upon lime-water. One of the constituents 
of the blood, serum, or rather albumen in solution, is passed with the 
urine in a great number of diseases, and in one, the large amount 
of it habitually discharged characterizes the malady, and has even 
conferred upon it a name, albuminous nephritis, or Bright's dis- 
ease. In another affection the urine is remarkable for the quan- 
tity of sugar contained in it, by which it acquires a sweet taste and 
has its density considerably increased. Sugar and urea, indeed, 
elevate the specific gravity of the urine more than do any others 
of its soluble constituents. The colouring matter of the bile com- 
municates to the urine a light or dark yellow colour, according to 
the quantity of it held in solution. Oxalate of lime is by no means 
an infrequent ingredient of the renal secretion, but it readily es- 
capes notice, and requires a particular manipulation of the urine 
for its detection. It is a prolific source of calculous concretions. 

Various other substances are met with in urine altered by disease, 
but they are of inferior consequence to those already enumerated. 
According to the chemists, the great number of them are not ori- 
ginal products, but result from the decomposition of urea and uric 
acid, and of the recomposition of their elements in new forms. 
The slightest disturbing influences seem capable of producing these 
changes. There is a wide difference between the physical charac- 
ters of sugar and oxalic acid, and between those of albumen and 
uric acid, and yet they have respectively so close a resemblance 
in their chemical composition, that the addition, subtraction, or 
transposition of a single element of one of them shall be sufficient 
to create another one of the number. The extreme facility of these 
transformations, and our almost total ignorance of the laws which 



MORBID URINE. 283 

regulate them, must, it would seem probable, render nugatory every 
attempt to account for the morbid states of the urine upon merely 
chemical principles. Such attempts appear still more likely to be 
unsuccessful when it is considered that the morbid states of the 
urine are, for the most part, effects rather than causes of disease; 
effects either of inflammation, or of some structural lesion of the 
kidneys themselves, or of some constitutional vice, or else, what is 
still oftener the case, of some derangement of the digestive function. 
The primary assimilation of the food may be imperfect, and hence 
the whole function of nutrition become disordered. 

A brief account of the modes of detecting in ordinary practice, 
the most important alterations of the urine, may not, perhaps, be 
misplaced here. The apparatus necessary for examining the urine 
at the bedside is very simple, and consists merely of a gravimeter 
for measuring the specific gravity of fluids, a little blue and red 
litmus paper, a test-tube, a spirit lamp, and a vial of nitric acid. 

The reaction of the urine is first to be tested ; if acid, it will 
redden blue litmus paper ; if alkaline, it will turn the red paper 
blue: if neutral, it will produce no change in either colour. If 
there is no cloud in the urine, a small quantity of it may be placed 
in the test-tube over a spirit lamp. Should a white deposit be 
formed, it must be either albumen or the earthy phosphates ; but by 
adding a drop of nitric acid, that question is settled ; for the acid 
will coagulate the albumen more firmly, but dissolve the salts. 

If the urine is very high-coloured, it maybe supposed to contain 
either the colouring matter of bile, or blood, or an excess of uric 
acid. If blood be present, heat will cause the liquid to lose its 
transparency, as will also nitric acid ; whereas heat will not affect 
the, bile pigment, and nitric acid will at once turn it green. If 
uric acid be the cause of the dark colour of the liquid examined, 
the addition of nitric acid will precipitate it in the form of a brown- 
ish sediment. 

Pale urine usually contains an excess either of water, urea, or 
sugar. If the first, its sp. gr. will be low; if either of the latter, 
its sp. gr. will be high. By adding a little nitric acid to a portion 
of urine contained in a test-tube, surrounded by cold water, feather- 
like crystals of nitrate of urea will be deposited, if this substance 



284 SEMEIOLOGY. 

be in excess. If no urea is found, the test for sugar may be ap- 
plied. This requires some time and caution, when the proportion 
of sugar is trifling. But, in most instances, it is sufficient to place 
a drachm or two of the suspected urine in a test-tube, with about 
half its weight of liquor potassre, and boil the mixture over a 
spirit lamp. The previously pale liquid immediately assumes a 
peculiar orange-brown colour. This test has been further perfected 
by Dr. Heller, of Vienna. After boiling the liquid for some time, 
if nitric acid be added, a very evident odour of molasses is per- 
ceived. 

Should the urine be alkaline, it remains to be inquired whether 
this state depends upon its containing albumen or ammonia. The 
addition of a little nitric acid will determine this point; for, if albu- 
men be present, a coagulum will be formed ; but if ammonia, a 
brisk effervescence takes place, in consequence of carbonic acid 
being liberated. 

If, instead of being clear, the urine deposits a sediment on stand- 
ing, its character may be determined by similar means. Thus, 
when the deposit is flocculent, and readily diffusible by agitation, 
it is made up chiefly of mucus, which is insoluble by nitric acid. 
When ropy or viscid, it may consist of the phosphates, or of mu- 
cus, or pus. The first are dissolved by nitric acid ; the second, if 
pure, remains unchanged ; and the last, if pure also, will be coagu- 
lated by the acid. 

The colour of the sediment aids in determining its nature. If 
white, it may consist of urate of ammonia, or the phosphates; but 
the former disappears under the action of heat, and the latter when 
nitric acid is added. If the deposit be coloured, it consists either 
of uric acid, or of urate of ammonia dyed with purpurine, or of 
blood. But the first can be recognised by its crystalline structure, 
the second by its disappearance when heated, and the last by its 
coagulating under the same influence. 

Dr. Golding Bird, from whose admirable essay these details are 
in great part derived, gives the following brief summary of the dia- 
gnosis of urinary deposits, which, if committed to memory, will 
be found a sufficient guide in nearly every case : " If the deposit 
be white, and the urine acid, it, in the great majority of cases, con- 



URINARY DEPOSITS. 285 

sists of urate of ammonia ; but if it should not disappear by heat, 
it is phosphatic. If a deposit be of any colour inclining to yellow, 
drab, pink, or red, it is almost sure to be urate of ammonia, unless 
visibly crystalline, in which case it consists of uric acid." 

The manner in which urine is voided is modified by disease. 
In health it is discharged at certain regular intervals, freely, and 
without pain. But, under various circumstances, the call to urinate 
may be almost constant; the stream may be more sluggish than 
natural, or interrupted, forked, twisted, or small ; or it may be 
passed without the patient's consciousness, or in spite of his at- 
tempts to control it. The last-named condition is called inconti- 
nence. There may be such extreme difficulty in voiding the urine, 
that it issues only in drops, and is attended with heat, pain, and 
tenesmus, about the neck of the bladder — this is strangury. If 
pain be absent, while the urine, as it were, distils from the ure- 
thra, there is said to be dysury. 

To complete this portion of the present subject, it remains to 
point out the semeiological value of the symptoms which have been 
described. Profuse and chronic discharges of urine, containing 
sugar, are characteristic of diabetes ; a like abundance, of a non- 
saccharine fluid, indicates the disease variously denominated dia- 
betes insipidus, hydruria, and polydipsia. Clear and transparent 
urine, containing neither blood nor mucus — frothing when agitated, 
and coagulating on the application of nitric acid and heat — is albu- 
minous, and, in chronic disease, indicates granular degeneration of 
the kidneys. During the first stage of Bright's disease, the urine 
contains blood corpuscles. Urine made green by the addition of 
nitric acid, contains the colouring matter of the bile. Crystals, a 
gritty sediment, and calculi, in the urine, announce the existence 
of some one of the forms of gravel, which is to be determined more 
precisely by the methods above described. Hydatids, in this fluid, 
generally proceed from a cyst in the kidneys. 

Mucus in the urine, if in considerable quantity, is generally 
owing to vesical catarrh, or to enlargement of the prostate gland. 
Pus may be derived from inflammation of the pelvis of the kidney, 
(pyelitis,) or from that of the lining membrane of any part of the 
urinary passages, or from an abscess of the kidney, or prostate 



286 SEMEIOLOGY. 

gland; and when sanious, foetid, and bloody, it is almost certainly- 
indicative of malignant disease of the bladder. Blood in the urine 
is commonly due either to inflammation of the kidney, to calculous 
concretions in its pelvis, or to erosion of a vessel in the bladder. 
It also frequently accompanies the course of a variety of acute and 
dangerous diseases. The urine in small-pox, for instance, is often 
bloody. So is it in purpura, in typhoid fever of bad type, in scor- 
butus, in acute anasarca from exposure to cold, &c. It may even 
occur as a distinct affection, without any general or associated 
symptoms. The manner in which pus and blood are voided, is of 
consequence in diagnosis. If they are discharged with the com- 
mencement of the stream, it may be presumed that they are formed 
in the urethra. If they accompany the conclusion only of the dis- 
charge, they are usually regarded as proceeding from vesical dis- 
ease, and, if intimately mixed with the urine, from the kidney. 
But it is evident that the value of this distinction is doubtful ; for, 
whether the bloody or purulent discharge proceed from the bladder 
or the kidney, it will, if the patient remain at rest, be voided only 
at the conclusion of urination ; and if he be in motion, it will mix 
with, and accompany in its emission, all the urine contained in the 
bladder. Bodies, looking Irke earth-worms, are sometimes passed 
from the bladder. They are coagula of blood, moulded in the ure- 
ters. They generally give rise, while in these canals, to the symp- 
toms of nephritic colic, or of a fit of the gravel. 

Frequent calls to urinate may be owing to a large increase of 
the renal secretion, and, when attended with pain, to a concentrated 
state of the urine, — to inflammation of the bladder — the ingestion 
or absorption of the active principle of cantharides, or of turpentine; 
to the presence of a calculus in the bladder, to enlargement of the 
prostate gland, to pressure of some adjacent organ or tumour, and 
to an excited state of the nervous system. Infrequency of voiding 
the urine depends, in disease at least, either upon its scanty secre- 
tion, (ischuria, suppression) or its retention in the bladder. Two 
forms of the latter are to be distinguished : the one in which a 
physical obstacle prevents the escape of the urine, and the other in 
which the patient's sensibility is so blunted that he is unconscious 
of the distention of his bladder. In the latter case, when a certain 



SIGNS FROM URINATION. 287 

amount of urine is collected, all beyond that quantity forces a pas- 
sage, and there seems to be incontinence, when there is in reality 
retention. In paraplegia, the amount thus retained becomes gradu- 
ally less and less, and at last the urine escapes from the urethra al- 
most as fast as it is poured into the bladder. Such incontinence is also 
not unusual after operations for the removal of stone in the bladder, 
especially when the patients are very young. A twisted, forked, 
or thin stream of urine, is commonly indicative of stricture of the 
urethra ; it may, however, be caused by a fragment of stone, or 
other foreign body, in this canal. 

The symptoms furnished by the urine are not without their value 
in prognosis. If, for example, they lead to the detection of diabetes, 
or the suspicion of Bright's disease, the most unfavourable judg- 
ment must be formed of the ultimate issue of the case. Here the 
certainty of the prognosis is entirely measured by that of the diag- 
nosis. In other circumstances, particular symptoms foreshadow 
the subsequent course of the attack. Thus bloody urine at the 
commencement of a febrile disorder is an exceedingly unfavourable 
occurrence ; in acute disorders generally, so long as the urine re- 
mains clear, or, if at all clouded, deposits no sediment, a speedy ter- 
mination of the attack ought not to be looked for ; while, on the other 
hand, when in the place of such urine, there is a discharge which 
presents, on standing, a copious lateritious sediment, a remission, if 
not the definitive resolution of the malady, is at hand. But even 
before the appearance of such deposits, the approaching decline of 
the attack can sometimes be predicted from an examination of the 
urine. It has been found, according to Martin-Solon, that the 
urine is albuminous in most acute diseases, just before the com- 
mencement of their decline. The sign is not however of much 
importance, inasmuch as it is often met with in cases which for a 
long time afterwards give no evidence of improvement, or which 
even terminate fatally. 

It need scarcely be remarked that the prognosis founded upon 
urinary symptoms, even when these are of the worst possible na- 
ture, depends in a great measure, also, upon their degree ; for even 
diabetes and Bright's disease, although incurable, are in many in- 



288 SEMEIOLOGY. 

stances so far amenable to treatment as to be prolonged far beyond 
the average duration which general observation would assign to 
them. A cautious prognosis should especially be given in calcu- 
lous affections, particularly at a period of life when a change of 
constitution may still be hoped for from a change of habits. 



CHAPTER IV. 

SIGNS FROM THE NERVOUS SYSTEM. 

The physiology of the nervous system is involved in so great 
uncertainty, that very few propositions relating to it are established 
by the general consent of scientific investigators. A correspond- 
ing, or rather an augmented, obscurity envelopes its pathology ; and 
in this darkness the physician must grope his way towards truth, 
conjecturing much and feeling sure of very little. This fact is the 
more to be regretted, because no other system furnishes so many 
remarkable symptoms as the nervous. Whether the patient sleeps 
or wakes, acts or suffers, all that he does or feels is through its 
agency. It is the power which presides over all the rest, the mo- 
ving influence of the whole animal machine. It not only governs 
individual parts, but harmonizes the action of all, (and that quite 
independently of the will,) binding together the several portions of 
a most complicated structure by the strongest, ties of sympathy, so 
that the well-being of one promotes the general good, and no one 
can suffer without affecting all. But those sufferings and disorders 
which claim particular attention in this place, are so varied in their 
sources, so uncertain in their nature, degree, and combination, are 
attended, for the most part, with such different lesions, if attended 
by any, that they are not only difficult to describe when first ob- 
served, but even more so to recognise when they recur. While 
the respiratory, circulatory, digestive, and every other apparatus, 
composed of anatomical elements differing widely amongst them- 
selves, has each a special and single function to perform, the ner- 
vous system, with an apparently simple anatomical arrangement, 
presides over three distinct functions, of whose physiology the 
rudest and grossest notions only have hitherto been obtained. It 
would seem impossible, therefore, to analyze processes in which 

25 



290 SEMEIOLOGY. 

all three of ihese functions, sensation, motion, and intellection, 
appear to be combined. Much has indeed been done by modern in- 
vestigators in explaining certain nervous phenomena, by first obser- 
ving the phenomena of disease which appear to be connected with 
definite lesions of structure, and then by imitating, as far as possi- 
ble, the same lesions in experiments upon the lower animals. The 
results of direct observation, rather than the explanations inferred 
from these sources, will be set forth in the ensuing sections. 



SECTION I. 

SIGNS FROM THE FUNCTION OF SENSIBILITY. 

The general sensibility ■, or common sensation, may be exalted, 
perverted, impaired, or altogether lost. In hysteria, in that state 
falsely called magnetic, in inflammation of the brain, and fevers, 
and during the decline of certain affections such as typhoid fever, 
it is often very acute. In acute meningitis, in rheumatic and scro- 
fulous ophthalmia, and in neuralgia of the eye, intolerance of light 
is often so extreme, that the patient finds no repose except in utter 
darkness ; in cerebral inflammations, and in some cases of hyster- 
ical disorder, the sensibility is so acute that the gentlest whisper 
may pain the ear, and the mildest odour offend the smell ; when 
the spinal meninges are inflamed, the cutaneous sensibility is so 
much exalted that the mere contact of the bed-clothes with the 
skin, or the least touch of an attendant's hand, may excite the most 
intolerable suffering. The last-mentioned symptom is not uncom- 
mon after acute diseases of an ataxic form, and has then no pecu- 
liar danger, but when it, or other forms of exalted sensibility, ap- 
pear at an early stage of an acute attack, without any structural 
disease of the organs whose functions are altered, they are unfa- 
vourable indications. They are much more serious when accom- 
panied with fever, than when they occur in persons of a nervous 
temperament, the morbid sympathies of whose organs are readily 



MORBID SENSIBILITY. 291 

excited ; for the presence of fever, under the circumstances, points 
to a probable inflammation of the brain. 

There is a form of exalted sensibility, not so much to external 
impressions as to those which depend upon morbid changes going 
on in the economy, and which in its several degrees may be 
spoken of as discomfort, restlessness, anxiety, and distress. The 
first of these is the ordinary precursor of acute attacks; the second 
is more commonly a sign of some complication about to arise in 
the course of another disease; the third and fourth are measures 
of the severity of such complication, and often precede the unfa- 
vourable change in a disorder which leads to its fatal issue. 

Pain is a sensation which many have attempted to define, but 
unsuccessfully. Nothing is known of its nature, and but little of 
what is essential to its production. In general, it results from 
some impression made upon the nervous extremities, and trans- 
mitted to the brain, where it is perceived. But in other cases, the 
impression is made at the origin of a spinal nerve, or in the spinal 
marrow, or in the brain itself, while the sensation is referred to a 
distant part of the body. This fact should be borne in mind, for 
when no sign of disease in a part can be detected besides pain, an 
examination of the trunk of the nerve distributed therein, as well 
as of the nervous centres, may lead to the discovery of its cause. 

The causes of pain have been arranged under the following 
heads : 1st, lesions of the organs where it is felt, such as wounds, 
bruises, lacerations, burns, the deposit of morbid products in their 
tissue, as in inflammation, cancer, &c. ; 2d, a healthful sensation 
unduly prolonged, or too intense, such as that produced by hunger, 
thirst, heat, and cold ; 3d, a sympathetic influence, as when pain 
in the shoulder is caused by disease of the liver, or pain in the 
glans penis by stone in the bladder; 4th, a functional, or at least 
not structural, disorder of the nervous apparatus, as in neuralgia. 

That all persons do not experience the same amount of pain 
under the same external circumstances, is a well-known fact ; the 
delicate and luxurious lady would sink under a hurt which a 
healthy labourer would scarcely allow to interrupt his occupation. 
Yet it is next to impossible to determine the degree of pain actually 
endured, since the onlv evidence of its existence is derived from 



292 SEM BIOLOGY. 

the exclamations and other manifestations of the patient, over 
which he has a certain degree of control. Moreover, in various 
depressed or excited states of the nervous functions, he may be 
actually insensible to injuries which at another time would have 
occasioned him severe distress. Children, females, hypochondriac, 
hysterical, and nervous persons, appear to suffer pain most keenly, 
and of these, females most of all. Yet they, in whom the nervous 
temperament is most fully developed, endure with heroic fortitude, 
not only the grievous pains peculiar to their sex, but the still more 
excruciating anguish inflicted by the surgeon's knife, particularly 
when the occasion requires them to moderate or to repress their 
cries. The concentration of the mind upon a subject, or a state 
of high mental excitement, will often produce complete insensi- 
bility to pain. Soldiers wounded in battle are frequently uncon- 
scious' of their hurt until the end of the combat allows them to 
think of themselves, or the loss of blood overpowers them. It is 
not uncommon for maniacs to be quite insensible to the severest 
cold, and to show no sign of suffering when they have mutilated their 
throats, genitals, or other parts, in attempting to commit suicide. 
The writer has seen a man seventy years of age, and who had 
been for a long time enfeebled in mind, with three carbuncles upon 
his back, two of them as large as a goose-egg, and that without 
his manifesting the slightest uneasiness, or any consciousness of 
an affection, which, under other circumstances, would have been 
intolerably painful. Whatever, in general, blunts the perceptive 
faculties, of course induces a greater or less degree of insensibility 
to pain, as may be daily seen in coma, from whatever cause aris- 
ing, in the paroxysms of epilepsy and hysteria; in the state of 
somnambulism; during the influence of alcohol, ether, chloroform, 
and narcotics. In diseases, therefore, attended with coma, exten- 
sive and dangerous complications may arise, without any con- 
sciousness on the part of the patient. 

Pain, then, is modified by the condition of the patient. It varies 
also according to the nature of its cause, being different, for ex- 
ample, in cancer, and in inflammation, and in the several degrees 
of the latter. The same agent may assuage one variety of pain but 
aggravate another; thus cold, which allays the pain of inflamma- 



VARIETIES OF PAIN. 293 

tion, increases that of neuralgia and colic. It may be continued, 
with exacerbations, (and this is its ordinary type,) or it may be 
intermittent, as in some forms of neuralgia. It varies, also, with 
the tissue affected, and is not always proportioned to the sensi- 
bility of this tissue in health. Perhaps the most intolerable of all 
pains are those of inflammation of the bones and fibrous textures, 
which have naturally but little sensibility. Serous membranes, 
also, show but little feeling when mechanically irritated, but are 
extremely painful when inflamed. Mucous membranes, on the 
other hand, are more tender in health than when diseased. 

The several varieties of pain have received different names, ex- 
pressive of their peculiar characters, which, in many instances, are 
sufficient for the discrimination of diseases. 

Dull or heavy pain is generally caused by the weight of some 
enlarged or congested organ, by the dragging of an internal 
tumour, or by an effusion into some serous cavity. In females, 
when felt in the loins, it frequently precedes the menstrual flow, 
and in males the formation of hemorrhoids. When seated over 
the eyes, it is frequently the precursor of epistaxis. 

Tensive pain exists when the affected parts are put upon the 
stretch, as when attempts are made to reduce a dislocation ; when 
the variolous eruption is about to appear or to maturate; in ascites 
and tympanites; or when purulent collections are forming in the 
cellular tissue. It is commonly accompanied with a throbbing sen- 
sation, in acute abscesses; with burning, in erysipelas, cutaneous 
inflammations generally, and carbuncles; and with a sense of tear- 
ing, in gout and rheumatism. The throbbing alluded to corre- 
sponds to the arterial pulsations. 

Smarting pain is chiefly felt when the skin, denuded of its cu- 
ticle, is exposed to the air, or any irritating substance comes in 
contact with parts which are naturally protected. 

Lancinating, or sharp and darting pain, is met with chiefly in 
neuralgia, rheumatism and cancer; it seems to follow the course 
of the nervous trunks, and is felt only for an instant in its greatest 
intensity ; in the intervals between its exacerbations there is either 
no pain, or one that is dull and contusive. In the several forms of 

25* 



294 SEMEIOLOGY. 

abdominal paroxysmal affections which go under the general name 
of" colic," the pain is at the same time lancinating and tensive. 

Perforating or gnawing pain, terms which sufficiently explain 
themselves, is chiefly experienced in rheumatism, gout, and inflam- 
mation of the periosteum and bones. It is common in the tertiary 
forms of syphilis, and then is most intense at night, as indeed are 
most of the pains accompanying disease of the fibrous and osseous 
tissues. 

Itching is a disagreeable sensation felt in many diseases of the 
skin : in scabies, for instance, which is emphatically called the itch, 
and in prurigo, a papular eruption, which is sometimes attended 
with such intolerable itching as to produce delirium. 

The degree of pain caused by a disease is no measure of its 
gravity. The most dangerous maladies, such as fevers, inflam- 
mations of the lungs, liver, and kidneys, pulmonary phthisis, and 
hydrocephalus, are attended with but little pain, and even when 
the inflammation of a parenchymatous organ extends to its invest- 
ing serous membrane, the increase of pain is scarcely evident, so 
long as the patient remains completely at rest, and even when ex- 
cited by pressure or motion, it is never so intense as that of tic 
douloureux, or of lead and other colics which are seldom fatal. 
The evil influence of pain consists in its exhausting the strength, 
and is therefore conspicuous in chronic affections, which, by pro- 
fuse discharges, or long confinement, have already produced gene- 
ral debility. It is under these circumstances that the greatest 
triumphs of moral courage over the progress of disease are wit- 
nessed ; when the constitutional cheerfulness or the religious con- 
fidence of the patient preserves his calmness and resignation amidst 
tortures which would drive another into gloomy despondency, or 
into outbreaks of passionate despair. 

Few persons can endure prolonged and unremitting pain ; such, 
therefore, is of evil augury. Movable or wandering pain is less 
serious than such as is fixed, and external than deep-seated pain. 
The occurrence of severe pains in the loins at the commencement 
of an eruptive fever indicates that it will be severe. The interrup- 
tion of the function of an organ by pain must be taken into account 
in estimating the prognostic value of this symptom. Thus, pain- 



EFFECTS OF FAIN. 295 

ful affections of the limbs are of much less consequence than those 
of the chest which interfere with respiration. Yet it must be ad- 
mitted that pain, alone, never interferes with the action of organs 
to a degree sufficient to produce death, although it has now and 
then extinguished life by means of the shock communicated to the 
nervous system. 

When pain ceases, and at the same time the strength suddenly 
fails, the pulse grows weaker, and the face sunken, it is often a 
sign that the affected parts have been attacked with gangrene, and 
have lost their previous sensibility. For a similar reason, the 
prognosis must be unfavourable when inflammatory or other com- 
plications, which are usually painful, arise without attracting the 
attention of the patient. A less serious, though extremely unpro- 
pitious circumstance, is the occurrence of severe pain during the 
decline of an attack, for it indicates either a relapse, or a new dis- 
ease, which must be dangerous in proportion to the debility already 
existing. Such untoward complications are pneumonia, which 
arises in the course of many acute diseases, endocarditis and peri- 
carditis in articular rheumatism, peritonitis after parturition, and 
during the decline of typhoid fever, &c. 

Pain confined to a single organ, and seeming of itself to consti- 
tute the whole disease, is commonly regarded as a form of neural- 
gia, and receives a corresponding name. Thus we havegastralgia, 
hepatalgia, nephralgia, enteralgia, &c, that is to say neuralgic 
pain of the stomach, liver, kidneys, bowels, &c. There is one 
organ, however, the head, which is the seat of some degree of pain 
in nearly every acute disorder, in all at least attended with fever, 
besides having its own local and peculiar pains. Cephalalgia, or 
headache, is a term used to designate a variety of pains in the 
head. One of its most common forms is that called nervous head- 
ache, and is extremely common amongst persons of an excitable 
disposition. In them it is brought on by whatever directly or indi- 
rectly debilitates: by bleeding, purging, fatigue, or getting the feet 
cold; by alcoholic stimuli, animated or angry discussions, loud 
noises, vivid lights, using the eyes too closely, powerful odours, 
prolonged study or thought, &c. These causes often produce a 
pain in the frontal region so intense that the slightest effort of body, 



296 SEMEIOLOGY. 

mind, or senses, is intolerable ; but if no other symptoms are pre- 
sent, the affection nearly always disappears after a few hours re- 
pose. Nothing is more common than for this pain to cease at sun- 
set, although it may have been extremely severe throughout the 
entire day. When along with it there is nausea or vomiting, with 
chilliness and depression of spirits, the attack is spoken of as sick 
headache, or migraine. 

Hemicrania, usually regarded as a form of headache, belongs 
to the neuralgia?. It is in most instances a neuralgic affection of 
the branches of the trigeminus which supply the brow and the side 
of the head, and of those of the occipital nerve which run forwards. 
At a point near the parielal protuberance, where the branches of 
these two nerves anastomose, is the seat of the severest pain, of that 
which in hysterical subjects has been compared to the suffering 
which a nail driven into the part might cause, and it is called from 
that circumstance clavus hystericus. 

Cephalalgia accompanies nearly every disease of the brain, its 
membranes, and the cranium. In cerebral congestion it is de- 
scribed as deep-seated, with a sense of fulness and weight in the 
head, dizziness, hazy or indistinct vision, and dulness of the intel- 
lect ; buzzing or humming noises are also heard in the ears, and 
the integuments of the face are swollen and red. The headache 
which marks the invasion of febrile diseases, the exanthemata, 
in particular, appears to be generally of this description, while, at 
the same time, the extreme sensibility to external impressions, the 
restlessness, and irritability, the indisposition to mental exertion, 
all indicate that the headache is, in part, also nervous. In the 
eruptive fevers it always abates, and often ceases, upon the appear- 
ance of the eruption. In typhoid fever it is more protracted, and 
when very intense, terminates in coma. 

When the meninges are inflamed, especially in children, the 
headache is, for the most part, very acute, and apt to extort that 
shrill and peculiar cry so often heard in tubercular meningitis. 
This pain may accompany diverse lesions of the cerebral mem- 
branes, injection of the capillaries, false membranes upon or with- 
in the arachnoid, purulent infiltration of the pia mater, or collec- 
tions of pus or serum in the ventricles, and is the same, whatever 



PAIN IN THE HEAD. 297 

point may be the seat of inflammation. It is characteristic of pain 
in the head, originating from such causes that it begins with the 
fhst symptoms of the disease, and goes on increasing until resolu- 
tion commences, or coma blunts the sense of suffering. 

In persons otherwise in good health, a constant and obstinate 
headache, or one marked by slight remissions only, ought to cre- 
ate suspicion of some organic disease within the cranium, unless 
the patient be young, of the female sex, and of an excitable tempe- 
rament. Insanity, and inflammation of the brain, or meninges, are 
often preceded for years by pain in the head and disturbed sleep. 
The prognosis will be the more unfavourable, if the pain is fixed 
and confined to a very small space ; and especially if, in connexion 
with these symptoms, there is formication, numbness, feebleness, 
or pain in the limbs of the opposite side of the body, or attacks of 
epileptiform convulsions. 

Chronic cephalalgia, marked by regular exacerbations, occur- 
ring at night, and rebellious to general and local agents of an anti- 
phlogistic description, is nearly always of syphilitic origin, and is 
immediately produced by an exostosis upon the internal or exter- 
nal face of the cranium. The pain which accompanies inflamma- 
tion and caries of the frontal, or of the mastoid or petrous portion of 
the temporal bones, is at first dull, then acute, darting, and excru- 
ciating beyond description. It is soon combined with symptoms of 
compression, or of inflammation of the brain, such as paralysis, 
or delirium, and is therefore a very unfavourable prognostic sign. 

Perversions of the senses, fyc. — rln some cases of cerebral con- 
gestion, and of inflammation of the brain, all objects appear red to 
the patient; in others, he perceives sparks, flames, fireballs, &c. 
Haziness and indistinctness of vision may be owing to an affection 
of the eye itself, (amaurosis, cataract,) or it may, as in some cases 
of tubercular meningitis, be the prelude to this affection. Dark, 
waving lines, points, and other ill-defined objects, floating in the 
field of vision, are most frequently accompaniments of dyspepsia, 
with derangement of the circulation, whether sluggishness or local 
determination. Double vision usually arises from strabismus, which 
has already been noticed ; but it may also occur during inflamma- 
tory and organic diseases of the brain, without sensible deviation 



298 SEMEIOLOGY. 

from parallelism of the axes of the eyeballs. Alone considered, 
this symptom is not of much value in diagnosis or prognosis. 
Sometimes only one half of an object is visible; the cause of this 
phenomenon is not well understood. It is met with occasionally 
in narcotic poisoning. MM. Hardy and Behier mention a case of 
poisoning by belladonna, in which the patient perceived at first 
only the one half of objects, and then they appeared to him upside 
down. t 

Unreal sounds, such as ringing, humming, whistling, or moan- 
ing, are very common symptoms in the pyrexias, and also in ane- 
mia and chlorosis. In the latter they are augmented by whatever 
quickens the circulation. They are occasionally heard by persons 
in a state of nervous excitement or anxiety. The writer has known 
a person, in a very anxious state of mind, pass whole nights awake, 
tormented with a sound precisely like that made by carpenters in 
shingling a roof, and which no effort of the will, or change of po- 
sition, succeeded in quieting. Such unnatural sounds sometimes 
give warning of epileptic attacks. They are also heard on the ap- 
proach of deafness, arising from inflammation of the ear, or partial 
closure of the Eustachian tube. 

When patients have a perception of unreal smells, in acute dis- 
eases of a low type, there is reason to apprehend that the disease 
is growing worse, particularly if the supposed smell be disagree- 
able. Nervous individuals are subject to such aberrations of sen- 
sibility, and in them they are without serious meaning. The cases 
alluded to, must not be confounded with those in which there is a 
foul secretion from carious bones, or from a mucous surface con- 
nected with the nasal fossae. 

The morbid alterations of the sense of taste have already been 
described, and those of the sense of touch alluded to under various 
heads. It will be sufficient to say of the perversions of the latter, 
in this place, that when a patient attributes to a body examined by 
the sense of touch, other qualities than really belong to it, there is 
reason to suspect commencing disorganization of the brain. 

There are two forms of morbid perception, which it is impor- 
tant to distinguish : illusion and hallucination. The former gives 
to external objects or occurrences a false interpretation ; the latter 



ILLUSION HALLUCINATION A NilSTHESIA. 299 

creates, out of the materials of thought, unreal objects or occur- 
rences. Both accompany various forms of insanity, but both may 
also exisi in minds only temporarily disturbed, and not insane. It 
is an illusion to take one person for another very different one ; to 
imagine a familiar friend transformed into an animal ; to hear pro- 
phetic sentences in ordinary conversation. It is an hallucination 
for one to suppose he is irrevocably doomed to perdition ; that he 
has committed a horrid crime ; that he hears the voice of the Al- 
mighty, or sees angels or the spirits of the departed around him. 
Hallucinations may annoy the most philosophical and well-balanced 
minds, and many are the cases in which distinguished persons of 
such character have described their visions, knowing them full 
well to be mere fictions of the brain. Others, less collected or 
less informed, have taken these phantoms to be real, and either 
founded fanatical sects upon their error, or promulgated the sur- 
prising ghost-stories, which startle the composure even of scientific 
men. 

Diminished sensibility may affect the whole, or a portion only, 
of the nervous system ; it may, also, as regards degree, be either 
partial or complete. Total loss of sensibility in a part is called 
ancesthesia. The phrase ' paralysis of sensation ' is sometimes 
employed to designate diminution or loss of the tactile power. 

Common as well as special sensibility are very generally im- 
paired in adynamic and ataxic fevers; the hearing grows dull, 
the sight dim, the smell and taste lose their acuteness, percep- 
tions of every kind become indistinct, and often when coma su- 
pervenes, sensation appears to be entirely lost. The same thing 
occurs in extensive disease of the brain, in concussion and com- 
pression of this organ, in apoplexy, and in serous effusion into the 
ventricles. Local anassthesia is not very frequently observed with- 
out a corresponding loss of voluntary motion, but the latter is con- 
stantly met with independently of any loss of sensibility, as in the 
paralysis which is caused by apoplexy. In this affection, as well as 
in many chronic disorders of the brain, it is not uncommon to find 
the palsied side more susceptible to cold and external impressions, 
generally, than the sound one. Some diseases of the spinal mar- 
row, especially such as are consecutive to caries of the vertebra, 



300 SEMEIOLOGY. 

are apt to impair sensibility without affecting motility. Aside from 
this class of cases, simple anaesthesia occupying any considerable 
portion of the body is usually functional. 

Diminished sensibility, it has been stated, may be either general 
or local. A case is recorded by M. Defermon, in which the entire 
body, with the exception of a small space upon the right cheek, 
became insensible, while the intelligence remained unimpaired. A 
somewhat similar state has been occasionally noticed upon the ap- 
proach of death. Andral relates of Baudelocque, the founder of 
modern obstetrical science, that in his last hours he repeatedly af- 
firmed that he was dead. He had lost his consciousness of every 
thing but his own existence. When the affection is local it may 
be confined to the hands, the feet, one side of the face, or other cir- 
cumscribed portions of the cutaneous surface. Such a condition 
is sometimes met with in hysteria, and in poisoning by lead, or 
may be induced by a cause acting directly upon the part, such 
as a blister, exposure to the sun, and erysipelatous inflammation. 
When the sense of touch is partially impaired, the patient is aware 
of the contact of external bodies, but cannot determine their den- 
sity or temperature, nor, without the aid of sight, distinguish their 
form and size. This symptom is frequently observed as the fore- 
runner of paralysis from cerebral or spinal disorganization. 

Insensibility without loss of motion generally exists in the state 
of somnambulism, and in hypnotism, or nervous sleep, artificially 
induced by acting upon the attention, the imagination, or the cre- 
dulity of the patient. Its production by the inhalation of ether and 
chloroform, and the fact that it is possible for a person to witness 
all the steps of a surgical operation performed upon himself with- 
out experiencing pain, are now familiarly known to medical men. 
The extraordinary but undeniable phenomena here adverted to de- 
monstrate the vanity of hoping to solve the mysteries of human 
organization by the mere perceptions of the anatomist or the ana- 
lyses of the chemist. 

In complete anaesthesia sensibility is lost, not only in the skin, 
but in the deep-seated parts, so that they may be burned, cut, or 
lacerated without producing the slightest pain. Hoffman relates of 
a young man who was paraplegic that he became aware that one 



DEBILITY. 301 

of his limbs was roasting at the fire, only by the smell which it 
emitted. Inflammation ol the soft parts, fracture of the bones of 
paralysed limbs, ulcers of the skin from pressure or the applica- 
tion of sinapisms, may take place without the consciousness of the 
patient ; and hence the practical caution to examine repeatedly the 
parts subjected to pressure in paralytic patients, and to avoid apply- 
ing to insensible portions of the skin blisters or other irritating 
agents. 



SECTION II. 

SIGNS FROM THE ORGANS OF VOLUNTARY MOTION. 

As already intimated, motility, or the power of motion, is closely 
connected with sensibility; it is regulated by the same organ, the 
brain, and is even more susceptible than the allied function, of 
being modified by disease. 

The only morbid states in which muscular power is augmented are 
those of cerebral or nervous excitement. Such increase of strength, 
when it depends upon inflammation of the brain or its membranes, 
as during the delirium of acute diseases, is a very bad sign ; it is 
commonly followed by coma and death. If, however, it is mani- 
fested in an attack of mania which, so far as our knowledge ex- 
tends, is a functional disturbance of the brain, the most prodigious 
display of muscular power has no peculiarly evil significance; it 
diminishes as the maniacal fury abates, and may be renewed with 
equal violence at the next paroxysm. 

Muscular debility occurs at some time in the course of nearly 
every disease. In such as are general, the pyrexia? or fevers, it 
commonly precedes the other symptoms, commencing as mere las- 
situde, and gradually increasing until the patient can no longer 
stand upright ; or it may, at once, assume this aggravated form, 
especially in epidemic and endemic diseases. In these it is not 
uncommon for a person to fall down suddenly, or to feel as sud- 
denly unable to proceed with the occupation that happened to en- 

26 



302 SEMEIOLOGY. 

gage him at the time. Muscular weakness occurs later in affec- 
tions of an inflammatory type, and is then due, either to conges- 
tion of the brain, impoverishment of the blood, or wasting of the 
muscular tissue. The last-named cause is alone operative when, for 
example, a person has been confined to bed with a sprained ankle 
or other affection which gives rise to little or no febrile reaction. 

Deterioration of the blood may be regarded as a cause of weak- 
ness, since in low forms of fever the fibrinous element of this fluid 
is deficient, and in anemia which is marked by great prostration, 
there is a diminished proportion of the red-globules of the blood. 
It is not improbable that these conditions become influential chiefly 
from their rendering the blood incapable of affording proper nour- 
ishment and stimulus to the nervous system. In low fevers, too, 
the loss of power due to the altered composition of the blood, is 
increased by the pressure of the overloaded blood-vessels upon the 
brain. Diminished power in consequence of cerebral congestion 
is a degree of paralysis ; when the congestion is greater, or termi- 
nates in apoplexy, the paralysis is complete. 

Paralysis, meaning literally, relaxation, (tfagot, Xuw) is properly 
applied only to loss of motion. It may be general or partial. It 
is usually confined to one side of the body, when it depends upon 
disease in either half of the brain, and is then called hemiplegia. 
It affects both sides of the lower half of the body when the lesion 
producing it is within the spinal canal, and is then termed paraple- 
gia. When much more restricted in extent, it does not often de- 
pend upon disease of either of the nervous centres, but more usu- 
ally upon some injury or merely functional alteration of a parti- 
cular nerve. This state ought not to be confounded with loss of 
power resulting from atrophy of one or more muscles. The move- 
ments of the arm, for instance, may be impaired or lost when 
the deltoid muscle wastes away in consequence of a contusion or 
of rheumatism, and may be regained if the muscle become de- 
veloped anew. Even when paralysis depends upon cerebral dis- 
ease, it is not necessarily permanent ; it often diminishes greatly, 
and occasionally is altogether cured. 

In the great majority of instances, paralysis from disease of the 
brain is seated in the side of the body opposite to that of the cere- 



PARALYSIS TREMBLING. 303 

bra! lesion. The exceptions to this rule are few, and not easily 
explained. It has also been maintained that when an upper ex- 
tremity is paralysed, the seat of the lesion is in the optic thalamus, 
and that a lesion of the corpus striatum produces palsy of the op- 
posite lower limb; but these alleged correspondences are not fre- 
quent enough to obtain the authority of laws. The worst forms of 
paralysis are those which accompany manifest and acute cerebral 
disease, apoplexy, for example. The gravity of this symptom is, 
indeed, entirely subordinate to that of the lesion upon which it de- 
pends, and the latter can only be inferred from the aggregate of 
the symptoms. Thus the prognosis must be looked upon as ex 
tremely unfavourable when the attack is sudden, the paralysis ex 
tensive and complete, and the loss of consciousness protracted 
and, on the other hand, when the paralysis advances gradually 
there is more reason to hope for prolonged life, if not for a com 
plete restoration of health. Paraplegia sometimes lasts for many 
years without greatly interfering with any function except locomo 
tion ; but when it occurs during fevers, and advances rapidly, it is 
of very sinister augury, especially if it involve the sphincter 
muscles of the anus and bladder. 

f Perversions of motility include the large class of convulsive dis- 
orders, as well those which are generally recognised to be of this 
sort, as others which are not less truly so, and which consist of 
involuntary and spasmodic movements. Trembling is one of the 
most familiar forms of perverted motion. It is usually accom- 
panied with coldness of the surface, when occurring in the cold 
stage of intermittent fever, or during the period of invasion of in- 
flammatory affections; but it may be a purely nervous disorder, 
as in ataxic fevers, and in persons of an excitable temperament. 
During convalescence from disease, it appears to depend upon 
simple muscular and nervous debility. It is also a consequence 
of receiving into the system particles of mercury and lead, by 
those who work at trades in which these metals are used, and is 
also a frequent result of excessive indulgence in venery, in alco- 
holic drinks, opium, tobacco, or coffee. The shaking palsy of old 
age is unconnected with any determinate lesion of the nervous 
centres. 4 



304 SEMEIOLOGY. 

Convulsions, properly so-called, affect two forms, the tonic (rsivw, 
I stretch), in which the muscles remain firmly contracted for a cer- 
tain space of time, and the clonic, (xXovotf, agitation,) in which there 
is a rapid alternation of muscular contraction and relaxation. Both 
forms may be either general or partial, and depend either upon some 
alteration of the brain or spinal marrow, or of their meninges, or 
upon sympathy with the disorder of some other organ, or else 
exist independently of any local disease of the nervous or other 
systems. The last named are called idiopathic convulsions, be- 
cause the physical changes which precede their development elude 
the closest scrutiny. Most of the cases of sympathetic and idiopa- 
thic convulsions are now regarded as illustrative of a physiological 
principle first fully developed by Marshall Hall. He showed that 
the whole muscular system is under the immediate control of the 
spinal marrow, which possesses a power of causing contractions 
in the muscles when a stimulus is applied either to them or to it. 
This, which is aptly denominated the reflex function, is independ- 
ent of volition, and governs all the involuntary movements, those 
of the respiratory, digestive, and cardiac muscles, and, in a parti- 
cular manner, the sphincters. The convulsions of infancy, so 
often attributable to the irritation of the gums during dentition, 
to the presence of worms, indigestible food, &c, in the digestive 
canal, those which follow emotions upon the mind, and the spasms 
of tetanus, in consequence of a wound, all illustrate the operation 
of this function. Through it, also, an unusual irritant applied to 
a part will excite contractions of the muscular apparatus associated 
with it in the performance of a given function ; thus, sneezing is 
produced by irritation of the nostrils; winking, by irritation of the 
conjunctiva; retching or vomiting, by tickling the fauces ; retrac- 
tion of the testicle, by a calculus in the ureter; spasmodic move- 
ments of a paralysed limb, when it is smartly struck, &c. 

Tonic spasms, or muscular contractions, occur in several de- 
grees, such as cramp, stiffness of the joints, permanent flexion of 
a limb, and tetanus. Cramp is a painful contraction of a muscle, 
lasting from a few minutes to several hours. Its most common 
seats are the gastrocnemii muscles and those of the abdomen. 
During pregnancy^ and when there is a large ovarian tumour, it 



TONIC CONVULSIONS. 305 

frequently attacks the lower limbs, in consequence of the pressure 
to which the sciatic or anterior crural nerve is subjected. In old 
persons, not previously subject to this affection, it sometimes indi- 
cates latent softening of the brain. It is, however, a common 
symptom of slight derangements of the health, and is excited by 
over-fatigue, indigestion, or cold feet, in nervous individuals ; also 
by drinking green tea, and by the immoderate use of tobacco. 

One of the most ordinary signs of softening of the brain is rigid 
flexion of the fore-arm upon the arm. This contraction of the 
flexor muscles of the limbs comes on gradually, and in that respect 
differs from an analogous symptom occurring in hysteria, but 
which disappears with the decline of the paroxysm. When the 
rigidity in question is observed after an attack of apoplexy, it is 
in most instances a sign that inflammation is going on around the 
extravasated blood, and therefore of an extension of the disease. 
But it is highly important to know that this symptom is not always 
of such serious consequence, that it is not, as was formerly sup- 
posed, pathognomonic of cerebral softening, but is sometimes pro- 
duced by a simple extravasation of blood in the brain, that it even 
occurs sometimes as a sympathetic phenomenon in diseases of the 
chest and bowels, and sometimes without any assignable cause. 
Permanent contraction of one or more muscles of the eye is also a 
sign of cerebral disease, especially of large effusion into the ven- 
tricles; but is much more frequently coincident with perfect health, 
as when it is congenital ; it may also depend upon rheumatism, 
dentition, or upon worms, or other irritating bodies in the intestinal 
tube. 

Tetanus is another and remarkable form of tonic spasm, and is 
generally owing either to inflammation of the meninges of the 
spinal marrow, or to a wound, usually of some tendinous, ligamen- 
tous, or nervous part. Hence it is divided into idiopathic and 
traumatic. The first named variety is always attributable, either 
to direct violence to the spine, or to the impression of cold, after 
exposure to heat. Sometimes the muscles which raise the lower 
jaw are alone affected, and the mouth is firmly closed; this is 
called trismus. When the muscles upon the posterior part of the 
trunk are involved, the body is bent backwards in the form of an 

26* 



306 SEMEIOLOGY. 

arch ; to this form the name of opisthotonos is given. Empros- 
thotonos and pleurosthotonos are terms respectively applied to de- 
signate the forward and lateral bending of the body in this disease. 

Catalepsy is a convulsive disease in which both flexor and ex- 
tensor muscles are in a state of tonic spasm ; for it is a peculiarity 
of the disease that a limb, or the whole body, retains for an indefi- 
nite period any position in which it may be placed. 

Clonic convulsions, or those in which muscular contraction and 
relaxation alternate with one another, are much more frequent 
than the form just described. Subsultus, or jerking of the tendons 
in low grades of fever are of this sort, and ranks amongst the un- 
favourable signs which are presented in the typhoid state ; it ac- 
companies great exhaustion. 

A grinding motion of the lower jaw exists in many cases of 
cerebral and meningeal disease, whether inflammatory or tubercu- 
lous ; this, with rolling of the head from side to side, is very cha- 
racteristic of meningitis in children. Hiccup is another partial 
convulsion, which is supposed to affect the diaphragm. It is of 
little consequence, except in diseases attended with prostration or 
collapse, and is in such cases an almost fatal sign. 

General convulsions are best illustrated by hysteria, epilepsy, 
eclampsia, and chorea. 

It is somewhat remarkable that clonic convulsions are less dan- 
gerous in proportion as they involve a greater number of muscles. 
When the whole muscular system is affected, the disease is either 
curable, as in most instances of hysteria and chorea, or else of 
very long duration, as in epilepsy ; after the death of persons suf- 
fering from either of these diseases, there is rarely found any 
lesion to account for the violent functional disturbance which had 
existed. On the other hand, when one muscle or set of muscles 
is spasmodically affected, there is reason to believe that the state 
depends upon an organic lesion of the nervous centres. 

Convulsions and spasms, generally considered, are more signifi- 
cant of danger in males than in females or young children, because 
in the latter classes they are very easily excited. They are less 
unfavourable at the commencement of an acute attack than at a 
later stage of its course, especially if then accompanied with other 



CLONIC CONVULSIONS SPASMS. 307 

signs of cerebral disturbance, such as delirium, coma, or paraly- 
sis. They acquire a peculiar gravity when connected with inju- 
ries of the head, profuse hemorrhages, or exhausting discharges of 
any description. When convulsions do not occur in the course of 
an acute disorder, they are generally paroxysmal, and are dan- 
gerous in proportion to the shortness of the intervals between the 
paroxysms and the duration of these latter. 

Much is said in medical treatises concerning spasm of the in- 
voluntary muscles of the heart, the stomach, the intestines, the 
bladder, the urethra, and some mention is made of spasm of the 
gall-ducts, of the ureters, the bronchia, and even of the arteries. 
Thus, it is stated by Dr. Williams, [Principles of Medicine^) that 
" spasm of the intestines in colic is induced by reflex irritation re- 
sulting from acrid matter in them" .... that "spasm of the 
bronchi so suddenly occurring in spasmodic asthma, also some- 
times arises from intestinal irritation," and that in the same way 
"the heart is liable to be excited by considerable irritation in any 
part of the body." Spasm of the stomach may possibly exist in 
that obstinate vomiting, without nausea, which is excited by preg- 
nancy ; but the diaphragm and abdominal muscles, which are 
principally, if not solely concerned in the act of vomiting, and 
which are voluntary muscles, are much more likely to be excited 
by the reflex irritation of the gravid uterus; the sensible resistance 
sometimes opposed to the passage of an instrument along the in- 
flamed urethra in either direction, and tenesmus of the rectum, 
may indicate spasm of these parts respectively ; but even in these 
cases its existence is inferred rather than demonstrated, and may 
plausibly be referred to the action of the voluntary muscles. 
" Intestinal spasm" caused by " acrid matter" is a double assump- 
tion, for no one has ever seen the former, and it is not very clear 
what the latter signifies. On the contrary, no fact is more fami- 
liar than that " spasmodic" pain in the belly accompanies over- 
distension of the bowels, and is at once relieved bv the discharge 
of flatus. In this case it is evident that the fibres of the intestinal 
muscles are elongated, not contracted, as it must be supposed they 
would be in spasm. The alleged "spasm of ihe bronchi" appears 
to have no demonstrable existence. Cases of nervous asthma mav 



308 SEMEIOLOGY. 

indeed exist, of asthma quite independent of structural alteration of 
the lungs and heart ; but their phenomena are quite as readily ex- 
plained by supposing the existence of spasm in the external 
muscles of respiration, and in those of the larynx, as by assigning 
to them a cause which, in the very nature of things, is incapable 
of demonstration. Spasm of the biliary ducts and of the ureters, 
in so far as it is connected with pain, is in the same category as 
that of the intestinal canal ; distension of these conduits by calculi 
is the ordinary cause of the pain in them called spasmodic, and 
may as readily be referred to overstretching of their fibres as to 
spasm, for there is no evidence that pain can be excited in these 
organs unless they are immoderately distended. Spasm of the 
capillary blood-vessels is confessedly an ideal state, but one which 
has figured as largely in medical theory as if it possessed a posi- 
tive and palpable value. It was the prominent feature of Cullen's 
theory of fever. This distinguished man taught that some of the 
causes of fever produced collapse of the brain, which occasioned 
universal debility of the voluntary muscles and extreme vessels, 
which, in its turn, was followed by spasm and constriction of the 
capillaries! At this hour it seems almost incredible that the great 
genius of Cullen should have been expended in weaving so flimsy 
a fabric as this hypothesis of the pathology of fever. 

The disorders of the mind, which may be properly treated of 
under the head of general semeiology, are such only as are symp- 
tomatic of some bodily disease. The various forms of insanity 
constitute a totally distinct class. In the latter, the affection is alto- 
gether functional ; it is one of symptoms alone. In the former, the 
symptoms are also signs — signs of some tangible alteration of the 
solids or fluids of the body, already revealed by other morbid phe- 
nomena. Insanity is rarely owing to ill health alone, but delirium 
and coma, in their several degrees, have always an evident con- 
nexion with some strictly morbid state. Insanity is of indefinite 
duration, lasting usually for weeks or months, and often for years; 
delirium, coma, &c, usually terminate in a few hours or days. 
There is, indeed, a delirium which is due to direct impressions upon 
the nervous system, but which usually subsides as soon as its ex- 
citing cause ceases to operate. This is observed in violent fits of 



DISORDERS OF THE MIND. 309 

anger, during hysterical paroxysms and painful parturition, and 
after epileptic fits, and severe surgical operations. 

Proper febrile delirium is nearly always preceded or attended 
by signs of cerebral disturbance : such as sleeplessness, headache, 
vertigo, altered tone of the voice, forgetful ness, flushed face, heat 
of head, and injection of the conjunctiva — symptoms indicating a 
determination of blood towards the brain. It may be either calm 
or violent. In the former case, the patient seems to retain a partial 
consciousness of his situation, and, if spoken to, while talking in- 
coherently to himself, may have his attention drawn to a particular 
subject ; or if opposed in his attempts to get out of bed, or commit 
any other impropriety, will offer no resistance. In some cases, de- 
lirium assumes very curious forms; the patient, for instance, 
whistles continually, or remains obstinately silent, or talks with a 
degree of fluency and correctness to which he is unused, or as- 
sumes a tone quite different from his ordinary one. This form 
usually presents itself combined with much debility, and some stu- 
por or dulness of apprehension, in fevers of an adynamic type, 
and towards the close of some cases of inflammation, especially 
those of inflamed internal organs passing into a state of suppura- 
tion, as in pneumonia, and puerperal peritonitis. 

Active or furious delirium is characterized by extravagant cries, 
shouting, laughing, imprecations, or the most ridiculous or obscene 
language. The patient seems in a violent passion, threatens or 
strikes every one within his reach, and attempts to destroy every- 
thing he can get hold of; or he breaks out into wild lamentations, 
wringing his hands, and tearing his hair; or in other instances, as in 
delirium tremens, he fancies himself pursued by. legions of devils, 
or that some other frightful danger besets him. In this form, the 
patient is wholly unconscious of what he says or does. On the re- 
turn of reason, he frequently supposes that he has been asleep and 
dreaming. In this respect, as well as in those already mentioned, 
delirium differs from insanity. The insane most commonly re- 
member, with singular accuracy, every word they have spoken, 
and every extravagance they have committed during the attack; 
and if this distinctness of recollection sometimes occurs after de- 



310 SEMEIOLOGY. 

lirium, it is only in exceptional cases. The two forms of delirium 
which have been noticed, may succeed or alternate with one another. 
When maniacal delirium supervenes upon the more tranquil form, 
it must usually be looked upon as a sign of meningeal or cerebral 
complication, and therefore as of very unfavourable augury. 

Like other perversions of the nervous function, delirium may be 
symptomatic of an affection of the brain, or sympathetic with dis- 
orders of other organs, or, finally, idiopathic. It appears to ac- 
company inflammation of the meninges, and of the surface of the 
brain, rather than lesions of its interior substance, with which, on 
the other hand, disorders of motility and sensibility more frequently 
coexist. 

The most numerous instances of sympathetic delirium are fur- 
nished by inflammations of the abdominal organs, and by diseases 
in which the composition of the blood is altered. The latter con- 
dition is influential in typhus and typhoid fevers, in purulent ab- 
sorption, and in scurvy ; anemia, too, characterized by an altera- 
tion of the blood, differing from that of the diseases just mentioned, 
is occasionally marked by delirium, especially in hysterical fe- 
males. 

Sympathetic is much more common than symptomatic delirium ; 
since, for every case of inflammation of the brain, or its mem- 
branes, there are many diseases of other organs which cause a 
temporary derangement of the intellect. This fact ought not to be 
lost sight of; for, if it is, the error may be committed of treating 
these sympathetic aberrations as if they depended upon actual dis- 
ease of the brain. It is certainly difficult, in many instances, to 
distinguish the two forms of disorder ; but the life of the patient 
may depend upon a correct diagnosis, and there can be no doubt 
that many lives have been sacrificed in consequence of an ignorance 
of the distinction alluded to. Many a case of commencing insanity * 
has been treated by copious depletion, merely on account of the 
mental disorder, when the paleness of the face, the languor and 
feebleness of the circulation, the palpable derangement of digestion, 
or the influence of some moral cause, imperatively indicated a very 
different management. Anemic delirium and puerperal mania, have 



DELIRIUM SLEEP. 311 

repeatedly been aggravated, or rendered incurable, by a similar 
want of discrimination. 

Suspended consciousness or sleep, in disease, presents several 
varieties or degrees, which have been distinguished by different 
names. These are, somnolence, coma, lethargy, and cams. Som- 
nolence, or drowsiness, is a state between waking and sleeping — 
of half-consciousness — from which the patient may easily be roused 
by a question addressed to him. Coma, or deep sleep, is generally 
described as of two kinds : coma vigil, or uneasy sleeping, when 
the patient talks to himself, while his eyes remain closed ; or, if 
spoken to, will listen or answer, and then fall asleep again. In 
coma somnolentiim, the patient remains motionless and silent, and, 
if roused, immediately relapses into his previous stupor. By le- 
thargy is understood a more prolonged comatose condition ; and 
by carus, a state of complete insensibility, from which no stimulus 
will arouse the patient. 

A morbid disposition to sleep has chiefly two sources; 1st, dis- 
order of the brain, from inflammation, concussion, or pressure 
caused by some disease within the cranium ; and 2d, sympathetic 
congestion. Perhaps all of these causes, except concussion, may 
be included under one general title, viz., pressure; for whether it be 
by blood, as in hyperemia, passive congestion, and apoplexy ; by 
serum or pus, as in dropsy and abscess ; or by a solid body, as a 
depressed fragment of the skull, or a tumour within the cranium, — 
the brain must still undergo compression. The degree of coma 
arising from these causes, other things being equal, is directly pro- 
portioned to the degree of pressure. Thus it is sudden, and very 
complete when a large apoplectic effusion into the ventricles takes 
place. It would seem, also, that compression must be effected with 
a certain degree of rapidity in order to produce the symptoms just 
enumerated; for oftentimes, when a tumour within the cranium is 
of very slow growth, the operations of the mind remain undisturbed, 
until the offending body acquires a very large size. Sympathetic 
congestion of the brain producing coma is observed in many severe 
inflammations of other parts, of the heart, lungs, and bowels, for 
example, and also in the pyrexia?, or low fevers characterized by a 
diminished proportion of fibrin in the blood. It is also met with in 



312 S EM EI O LOGY. 

the congestive or cold stage of malignant intermittents, in all cases 
of asphyxia, of poisoning by carbonic acid gas, by the emanations 
of lead, and by over-doses of alcohol, opium, and other narcotics. 

Coma is an ordinary symptom of idiopathic jaundice, and of 
suppression of urine; in these cases, as well as in several of those 
already mentioned in which the blood undergoes a sensible altera- 
tion, it may be fairly presumed that such alteration is efficient in 
producing the symptom in question, because the circulating fluid 
no longer affords a sufficient and natural stimulus to the central organ 
of the nervous system. That various degrees of loss of conscious- 
ness may be entirely independent of pressure upon the brain is 
shown by the phenomena of natural sleep, by those of concussion 
previously noticed, of syncope, and of the state called trance, in all 
of which it is apparent that the brain itself is the starting-point of 
the influence which brings torpor upon its faculties. Surprising 
instances of prolonged sleep are related by authors. Van Svvieten 
mentions the case of a man who, after strong mental excitement, 
slept for four months, during the first two of which he was perfectly 
insensible to all impressions ; and another of an individual who 
without appreciable cause, and at intervals of one and two years, 
slept from one to four months. 

The dependence of coma upon such opposite conditions of the 
economy imposes upon the practitioner the duty of ascertaining its 
origin and complications in each particular case. The following 
circumstances will generally aid him materially in forming his 
diagnosis. If the face be pale, the temperature of the surface 
equable and moderate, the pulse feeble, and there be no paralysis, 
the coma not profound and the attention of the patient can be mo- 
mentarily arrested ; the attack may be generally referred to ex- 
haustion in consequence of prolonged mental or bodily effort, or 
the endurance of severe pain. A sudden attack of coma, the loss 
of consciousness and motion, a labouring pulse and stertorous res- 
piration, indicate cerebral congestion or apoplexy ; the former if 
the symptoms are transitory, the latter if they are protracted. 
When coma supervenes gradually, following pain in the head, 
fever, delirium, and spasms, it is a sign of effusion consequent upon 
meningeal inflammation. 



COMA. 313 

The foregoing remarks are sufficient to show that the importance 
of coma as an element of prognosis depends in a great measure 
upon its cause. It may perhaps be stated in general terms that 
when this symptom is associated with a low pulse, laborious or ir- 
regular respiration, a tracheal rattle, coldness of the extremities, 
paralysis of the organs of deglutition and excretion, profuse and 
viscid perspiration, and insensibility of the eye to light, it is an al- 
most unfailing precursor of death ; and that, on the other hand, 
when it is associated with regularity of the pulse and respiration, 
a proper distribution of heat, and degree of moisture, it is not only 
unattended with danger, but sometimes even salutary, by recruiting 
the exhausted vigour of the system. Aside from exceptional cases, 
it must, however, be admitted that comatose sleep is dangerous, 
while the nearer a patient approaches to his natural manner of 
sleeping the greater is his chance of recovery. These circum- 
stances are important to be noted in the diseases of infancy, as> 
indeed, are all the automatic or instinctive acts of infants, for they 
constitute almost the only language in which these little sufferers 
express their feelings. It is sometimes of consequence to be in- 
formed of a patient's habits of sleeping, lest the not unexampled 
error be fallen into of attributing a natural disposition to snore to 
cerebral oppression, or a dry mouth and tongue, depending simply 
upon a habit of sleeping with the mouth open, to a dangerous de- 
gree of fever. 



27 



CHAPTER V. 

SIGNS FROM THE CIRCULATORY APPARATUS. 

The heart, with the arteries and veins, constitutes the mechanism 
by means of which blood adapted to the purposes of nutrition is 
distributed over all the body, and having performed its office and 
passed through the lungs to be depurated, is carried back to its 
starting-point, and is then again despatched upon its life-giving 
errand to every molecule of the economy. In health this indis- 
pensable function is. performed with extreme regularity, an equal 
amount of blood having the same composition is every minute 
propelled into the arteries, undergoes the same unvarying changes 
in the capillaries, and with unfailing regularity returns through the 
veins to the right side of the heart. The same series of motions in 
the heart and vessels perpetually recurs ; the central engine which 
irrigates the whole system, gives out the same incessant sounds, 
while the stream which it propels glides noiselessly through its ap- 
pointed channels. But this regularity, this moderation, this rhythm 
of sound and movement, may be impaired by disease; certain al- 
terations result from disease affecting the circulatory apparatus 
itself, others from the consensus, or sympathy, of this apparatus in 
the disorders of other portions of the organism ; a part of them are 
vital, and the symptoms by which these are revealed cannot be 
explained ; a part, also, are physical, and can be directly traced to 
physical causes. For the comprehension of these latter an evident 
prerequisite is a knowledge of the mechanism by which the natural 
movements and sounds of the organs of circulation are effected. 
The normal sounds and movements being known, any departure 
from these indicates disease, and experience, including a study of 
symptoms, and of lesions revealed by dissection, teaches what par- 
ticular modification of either is the attendant of a given disease. 
Before proceeding, therefore, to a history of the signs of disease 



NATURAL POSITION OF THE HEART. 315 

furnished by the circulatory apparatus, it becomes necessary to 
propose a theory of the sounds and movements of the heart. We 
say a theory because there are several, all of which it is believed 
contain some elements of truth, but none embrace the entire truth. 
That which is set forth in the following pages appears to unite all 
that is demonstrable in the current theories, and at the same time 
to avoid most of their inconsistencies. 

The natural position of the heart, fyc* — The heart is attached to 
the lungs by the veins supplying the left auricle; these veins issue 
from each lung at about an equal distance from the centre of the 
left auricle, which is in front of the sixth and seventh dorsal ver- 
tebras. The outer boundary of the right auricle is from one to 
two inches to the right of the sternum. The right ventricle lies 
immediately behind the lower half of the sternum, and the third, 
fourth, and fifth costal cartilages of the right side. The left ven- 
tricle usually projects an inch beyond the right. Its outer bound is 
usually behind the left nipple, and its apex is behind the lower edge 
of the fifth rib, close to the costal cartilage. The valves of the pul- 
monary artery are commonly behind the sternal end of the second 
left intercostal space. The aortic valves are nearly behind the 
centre of the sternum, and opposite the third costal cartilages. The 
arch of the aorta, in its passage backwards and to the left, is behind 
the first bone of the sternum, and in front of the fourth dorsal ver- 
tebra. After leaving the pulmonary artery, the aorta passes to the 
right, and upwards, along the edge of the sternum, to about the 
middle of the first intercostal space, where the arch, strictly speak- 
ing, commences. It then passes in front of the trachea, and lies 
close behind the sternum near its upper edge. The tricuspid valve 
lies behind, and a little to the right of the centre of the sternum, some- 
what lower down than the aortic valves ; the mitral valve is at the 
same level, but is more deeply seated. These are assigned as the 
average positions of the parts enumerated, but they are by no 
means literally exact ; for even the healthy heart changes its place 

* Many of the particulars relating to the normal situation of tho heart and 
lungs are borrowed from a very original and interesting paper by Mr. Sibson, 
published in Vol. XII. of the Transactions of the (English) Provincial Me- 
dical and Surgical Association. 



316 SEMEIOLOGY. 

according to the capacity of the chest, the degree of repletion of 
the stomach, the activity of the circulation, &c, but they will serve 
as guides for examining into the condition of the several portions 
of the heart and great vessels which are most frequently the seat 
of disease. 

On applying the ear to the precordial region of a healthy per- 
son two sounds are heard, and an impulse is felt. The first of 
these sounds is duller, more prolonged, and seems more distant 
than the second ; it is loudest between the fourth and fifth ribs, and 
a little below and external to the left nipple, or about an inch above 
the point where the impulse of the heart is most distinct. It is 
heard at the same instant when the impulse is perceived, and a 
moment before the radial pulse can be felt. The second sound is 
shorter, clearer, seems more superficial than the first, and is most 
distinctly audible at the junction of the third left rib with the ster- 
num. The impulse is strongest about an inch below, and a little 
exterior to the left nipple. These sounds, and this impulse form a 
little series of phenomena which is repeated from sixty to eighty 
times a minute in a healthy adult, each repetition of it correspond- 
ing to one beat of the artery at the wrist. The series is made up 
in the following manner. First, the dull, prolonged sound, coinci- 
ding with the impulse; next a brief interval of silence; then the 
short, sharp, or second sound ; then a longer interval, at the con- 
clusion of which the first sound is again heard. As the whole of 
this series is accomplished in less than one second of time, the dif- 
ficulty of analyzing it must appear to be very great, and yet the 
practised ear finds the task an easy one. It results from such an 
analysis that the first sound consumes about one-third of the time 
employed by the entire series ; the short interval nearly one-sixth ; 
the second sound one-sixth; and the long interval one-third. 
Hence, it is perceived, that the duration of each sound is equal to 
that of the interval of silence immediately preceding it; the short 
silence and the short sound are equal, and so also are the long si- 
lence and the prolonged sound. 

The question now presents itself, how are these sounds and this 
impulse effected 7 In man, the heart is double. There are the 
systemic and the pulmonic hearts, identical in all essential points 



MOVEMENTS OF THE HEART. 317 

of structure and function, and differing only in strength, because 
the one has to supply the remote parts of the body with blood, and 
the other adjacent parts only, to wit, the lungs. For the present 
purpose then, the pulmonic heart may be left out of the question. 
The movements of the heart cannot often, it is plain, be studied 
upon the human subject ; experimentally, never. Observers have 
therefore been obliged to resort to vivisections of the lower ani- 
mals, or to dissection of them immediately after their being de- 
stroyed by a blow upon the head or by poison, the circulation being 
maintained meanwhile by artificial insufflation of the lungs. The 
last-mentioned procedure is liable to many objections, the most 
prominent of which are the exposure of the lungs to the air by 
opening the chest, and the consequently imperfect action of these 
organs, on which account the cavities of the heart become gorged 
with blood. The dissimilar results, in some respects, which have 
been obtained by the vivisections of frogs and other cold-blooded 
animals, in which the movements of the heart are naturally very 
slow, only tend to strengthen these objections. The minuteness 
of the organ in the case of the animals just named must be ad- 
mitted as adverse to the reception of the results of experiments 
upon it, so far, at least, as the rhythm and mode of generation of 
its sounds are concerned, but the smallness of its bulk presents no 
obstacle whatever to a satisfactory analysis of its motions. On 
the other hand, the movements of the hearts of large warm-blooded 
animals, when the circulation is maintained by artificial respiration, 
are so tumultuous and irregular that the order of their succession 
cannot be clearly determined, while the sounds produced in such 
hearts can be readily localized, because the points at which they 
are chiefly generated are at an appreciable distance apart. In seek- 
ing for the cause of a cardiac sound, it is evidently no matter how 
irregular the movements of the heart may be, provided that the 
point at which it is formed, and the uniform coincidence with it of 
a given movement can be ascertained. The rhythm of the heart's 
movements may therefore be determined with greatest certainty by 
inspecting the hearts of reptiles and other cold-blooded animals, 
while for that of the sounds, the hearts of large warm-blood ani- 
mals afford the safest data. The hearts of the amphibia and of 

27* 



318 SEMEIOLOGY. 

some of the larger fishes, the sturgeon for example, would probably 
serve to illustrate the mechanism, as well of the movements, as of 
the sounds of the heart, but it is believed that no experiments have 
been made upon these animals with reference to the point in ques- 
tion. 

The heart consists essentially of two muscular cavities, an 
auricle and a ventricle, the former receiving blood from a vein, 
the latter receiving its blood from the auricle, and propelling it into 
an artery. A set of valves exists between the auricle and ven- 
tricle, opening towards the latter, and another set between the 
ventricle and the artery, opening towards this vessel. The auricle 
throws its contents but a short distance, into the ventricle, its mus- 
cular walls are therefore comparatively feeble ; the office of the 
ventricle is to force the blood through distant vessels, its walls are 
therefore thick and strong. Now by what succession or combina- 
tion of movements is the blood transmitted from the entrance of 
the auricle to the outlet of the ventricle 1 Ever since the time of 
Harvey and of Haller, it has been universally admitted that the 
auricle contracts and throws its contents into the ventricle, which, 
in its turn, expels the blood into the arteries, and that then a mo- 
mentary pause ensues. Observers are not unanimous respecting 
what takes place during this interval of the heart's repose. Several 
of the most distinguished insist that the ventricle remains contracted 
and empty, while the auricle becomes distended during this pause, 
and at the end of it throws its entire contents forcibly into the ven- 
tricle; but the modern English, Irish, and American experimenters 
declare that no sooner has the ventricle expelled its blood, than it 
begins to relax, and to fill up partially with blood, which runs into 
it from the auricle, without any active contraction on the part of 
the auricle. At the end of the pause, they further mention, the 
ventricle being nearly full, and the auricle quite so, there is a 
slight contraction of the auricle, followed immediately by the con- 
traction, or systole, of the ventricle. The difference between the 
two parties, is, summarily, this: the one maintains that the dilata- 
tion, or diastole, of the ventricle is instantaneous, and caused by 
its sudden reception of the whole contents of the auricle; the other, 
that the ventricular diastole is gradual, occupying the whole of the 



IMPULSE OF THE HEART. 319 

pause, and that it precedes the auricular systole, whose only office, 
according to this theory, is to complete the distention of the ven- 
tricle, and stimulate it to contraction. Or, to express the differ- 
ence in other terms : it is affirmed, on the one hand, that the dias- 
tole of the ventricle is wholly and entirely dependent upon the 
auricular systole ; and on the other, that the consummation, only, 
of the ventricular diastole is dependent upon this cause. It is 
agreed upon both sides, however, that no sooner has the diastole 
of the ventricle taken place than this cavity contracts, and with 
such rapidity, that no interval whatever between its diastole and its 
systole can be perceived. The contraction of the auricle, the en- 
tire, or complementary, dilatation of the ventricle, and the con- 
traction of this latter, succeed one another so immediately as to 
form but one continuous movement, during the performance of 
which the first sound of the heart is heard, and its impulse felt. 

What, now, gives rise to this impulse? The more generally 
received opinion is that of the party maintaining the diastole of the 
ventricle to be slow and gradual, and is that the impulse is due to 
the shock of the apex of the heart against the parietes of the tho- 
rax, during the systole of the ventricle, and to this cause alone. 
The doctrine which appears to be most strictly in accordance with 
facts, is, that the cause of the impulse is the diastole of the ven- 
tricle, its force being proportioned to the power with which the 
auricle propels its contents into the ventricle. Independently of 
all experiment, it would be difficult to comprehend how the con- 
traction of a hollow muscle could have any other effect than to 
diminish its volume, or that it could, while contracting, give a 
blow to a body external to itself. But vivisections of cold-blooded 
animals confirm the justness of this objection to the received doc- 
trine. When the heart of a frog, which is transparent, is exa- 
mined, the apex is seen to be thrust forward at the same instant 
that all the dimensions of the organ are enlarged, and its colour 
shows it to be distended with blood, while the apex is retracted 
simultaneously with the lessening of (he size, and the disappear- 
ance of the colour of the heart. In other words, tho projection of 
the apex corresponds with the diastole, and its retraction with the 
systole of the ventricle. Certain cases of malformation go to con- 



320 SEMEIOLOGY. 

firm this view. One such is reported by Cruveilhier, to this effect. 
A child was born with a deficiency in the upper part of the ster- 
num, through which the heart projected. It lived nine hours. In 
this case the contraction of the auricles was exactly synchronous 
with the dilatation of the ventricles. During the ventricular sys- 
tole, the heart contracted in every diameter, and no part of it was 
thrust forward except the apex, and that only with a slow spiral 
motion. The ventricular diastole, on the other hand, " had the 
rapidity and energy of an active movement triumphing over pres- 
sure made upon the organ, so that the hand closed upon it was 
opened with violence." This movement was accompanied with a 
strongly marked projection of the heart downwards. The rapidity, 
energy, and direction of the ventricular diastole here observed, de- 
monstrate this movement to be the cause of the cardiac impulse. 
Very similar phenomena were presented in an analogous case 
reported by Dr. Robinson, of Petersburg, Va., in 1833; and both 
cases, it is plain, are in every respect confirmatory of the results 
obtained by vivisections of cold-blooded animals. The combined 
evidence thus very summarily and imperfectly produced, warrants, 
it is believed, the conclusion, that actual inspection of the move- 
ments of the heart, when made under favourable circumstances, 
teaches that the impulse is synchronous with, and caused by, the 
diastole of the ventricles. 

There is another proof of the same proposition derived from con- 
sidering what takes place in hypertrophy of the ventricles. It is 
commonly taught, that hypertrophy of the heart is accompanied 
with augmented impulse. Laennec, Corvisart, and nearly every 
writer upon diseases of the heart, and upon the application of 
physical methods to their examination, affirm it ; and Dr. Latham 
goes so far as to say, that " hypertrophy cannot exist without ex- 
cess of impulse." One would suppose that such uniformity of doc- 
trine could only result from great clearness and constancy in the 
evidence of facts; that -it was a legitimate induction from many 
well-observed cases of hypertrophy. And yet it is no more than 
a deduction from an imperfect theory ; the testimony of observa- 
tion is directly adverse to its truth. Indeed, several observers have 
pointed out the fact, without succeeding in explaining it, that the 



CAUSE OF THE HEART'S IMPULSE. 321 

impulse is not always proportioned to the degree of hypertrophy. 
Thus, Dr. Pennock, in his valuable edition of Hope, says, " that 
hypertrophied hearts do not always beat with the force that might 
have been anticipated." Dr. Corrigan, of Dublin, in analysing a 
number of cases of ventricular hypertrophy, declares that " in all 
of them the impulse of the heart was less than natural, and in some 
could not be felt at all." Andral asserts that " the impulse is not 
necessarily increased in every case of hypertrophy; . . . and that 
in some cases of concentric hypertrophy, there is no perceptible 
impulse." Chomel, in like manner, informs us " that patients are 
not unfrequently met with, in whom the heart has become uncom- 
monly developed from hypertrophy and dilatation of its cavities, 
and yet without the energy of its impulse being increased, and 
even with a positive decrease of its normal force." These cita- 
tions might be multiplied, and confirmed by the analysis of cases 
of ventricular hypertrophy; but they suffice to show that if, as a 
general rule, increased development of the ventricle coexists with 
an augmented impulse of the heart, this coincidence is far from being 
uniform. 

Now, from what does this discrepancy arise? How does it hap- 
pen that hypertrophy of the ventricle is sometimes accompanied 
with diminished, and sometimes with augmented, impulse? It evi- 
dently cannot be explained upon the supposition that the impulse is 
due to the systole of the ventricle, and proportioned to the muscu- 
lar power of its walls ; and it must remain inexplicable, so long as 
this theory of the impulse is adhered to. But if, laying theories 
aside, we compare any number of cases of cardiac hypertrophy, 
showing increased impulse, with another series in which the im- 
pulse is diminished, we arrive at a curious result, viz. : that in every 
one of the former class of cases, there is auricular hypertrophy, 
either alone or in combination with a like state of the left ventricle ; 
and that where the impulse is not augmented, or feebler than 
natural, there is either dilatation and thinning of the auricle, or the 
hypertrophy is altogether confined to the ventricle; in one word, 
we find that, permanently augmented impulse of the heart coin- 
cides with auricular hypertrophy, 

A further confirmation of this proposition is derived from the 



322 SEMEIOLOGY. 

following pathological fact. It is well known that, under several 
circumstances, the pulsations of the heart do not agree in number 
with those of the arteries ; that two or three of the former may be 
felt for one of the latter. Now, if the impulse of the heart were 
owing to its systole, the cardiac and arterial pulses should coincide 
exactly, since the heart cannot contract without throwing some 
blood into the arteries, and producing a pulse in them ; but as there 
may be several cardiac impulses felt, for one that is arterial, it is 
plain that the prevalent theory is at fault, while that which has 
been proposed in the foregoing remarks furnishes an adequate so- 
lution of the difficulty. The want of correspondence between the 
cardiac and arterial pulses is observed chiefly in two cases ; first, 
when the heart is feeble; and, secondly, when its mitral orifice is 
obstructed. In both cases, a smaller quantity of blood than natu- 
ral is at first thrown from the auricle into the ventricle, a quantity 
insufficient to distend the latter cavity, or to stimulate it to con- 
tract ; at each contraction of the auricle, the ventricle is partially 
filled, and each time strikes against the ribs ; but its own systole 
does not take place until its repletion is accomplished. 

If, then, it may be regarded as proven that there is a constant 
connexion between augmented cardiac impulse and auricular hy- 
pertrophy, on the one hand, and between this hypertrophy and the 
energy of the ventricular diastole, on the other, — and further, that 
the cardiac impulse is synchronous with the ventricular diastole — 
the conclusion is irresistible that the impulse of the heart is caused 
by the diastole of the ventricle, and proportioned to the muscular 
power of the auricle. 

The cardiac murmurs. — It has already been stated, that while 
the auricle is contracting, and the ventricle dilating and again con- 
tracting, not only is an impulse felt, but a sound is heard, a dull, 
prolonged, and distant sound. By what mechanism is it produced? 
Those who believe that the sound in question coincides with the 
systole of the ventricle alone, differ somewhat from the advocates 
of the theory which has just been illustrated. Both parties, how- 
ever, agree in the following points, viz. : 1st. That one cause, and 
a principal one of the first sound of the heart is, the contraction of 
the ventricle ; because that sound is audible even when the heart 



THE SOUNDS OF THE HEART. 323 

of an animal is removed from its body, and its cavities emptied ; 
and because all muscular contraction is sonorous. 2d. That the 
first sound is augmented by the impulse of* the heart against the 
ribs. 3d. That it may, perhaps, be increased by the sudden clo- 
sure of the mitral valve, and the friction of the blood, during the 
ventricular systole. But, upon a fourth point, the two parties differ. 
The one which maintains the diastole of the ventricle to be slow 
and gradual, refuses to this movement the power of generating any 
sound ; the other, insisting upon its rapidity and energy, and at- 
tributing it to the sudden irruption of the contents of the auricle 
through the auriculo-ventricular orifice, naturally infer that the 
chief causes of the sound in question are, the passage of the blood 
through the orifice mentioned, and the shock of this fluid against 
the parietes of the ventricle. The first sound has a greater dura- 
tion than the impulse, and even than the diastole. It is prolonged 
during the systole, upon the one hand, and when the auriculo-ven- 
tricular orifice is narrowed, becomes audible before the impulse is 
felt. It may, therefore, be admitted, that all of the causes men- 
tioned conspire to form the first sound. 

As regards the second sound of the heart, there is but one mode 
assigned for its production which is inaccessible to criticism, al- 
though several others have been set forth and ingeniously defended. 
When the heart of a large animal, which has been rendered insen- 
sible, is exposed by opening the thorax, and a hook is introduced 
into the aorta in such a manner as to prevent the closure of the 
aortic valves, the second sound ceases to be heard ; if the hook be 
withdrawn, the second sound again becomes audible. This expe- 
riment is conclusive, for its evidence is both positive and negative. 
It was several times performed by Dr. Pennock, and always with 
the same result ; and it would be difficult to imagine that it con- 
cealed any possible sources of error. It teaches that the second 
sound is due to the closure of the semilunar valves, the column of 
blood being thrown back upon them by the resiliency of the artery. 

To combine in a few words the conclusions of the preceding ar- 
gument. The time occupied by one revolution of the series of phe- 
nomena which are constantly occurring in the heart, may be 
divided into four stages or periods. In the first period the auricle 



324 SEMEIOLOGY. 

contracts, causing the diastole of the ventricle, the first part of the 
first sound and the impulse, and the ventricle contracts, causing 
the prolongation and conclusion of the first sound. In the second 
period, or short pause, the ventricle remains contracted, and the 
auricle begins to fill. In the third period, the semilunar valves 
are thrown against one another, producing the second sound. In 
the fourth period, or long pause, the ventricle remains contracted 
while the auricle becomes fully dilated. At the end of the long 
pause, the auricle contracts anew, and the series is repeated. 

Signs from disease of the heart. — Beginning with the signs 
drawn from inspection and percussion of the precordial region, it 
may be remarked that this region is sometimes observed to project, 
or to present a convexity different from that of the rest of the 
thorax. It is generally due either to an effusion in the pericar- 
dium, or to an enlargement of the heart. In both of these cases, 
the dulnesson percussion, which naturally does not extend beyond 
a space of two inches square, is much more extensive, and may 
even reach from the right side of the sternum to beyond the left 
nipple. The chief distinguishing characters of the two affections 
is, that the former, except when it accompanies general dropsy, is 
the consequence of an acute attack of inflammation of the peri- 
cardium, and is therefore comparatively sudden in its invasion, 
while the latter is a disease of gradual and extremely slow growth. 
In emphysema, too, the precordium may be prominent ; but in 
that case the projection is not distinctly circumscribed, and percus- 
sion upon the part is resonant, and not dull. Precordial dulness 
may also be due to tumours occupying the mediastinum, either 
tuberculous, cancerous, aneurismal, or purulent. In such cases, 
however, the diagnosis must be settled by the commemorative and 
other symptoms which are detailed in works on the Practice of 
Medicine. 

d 

In health, the impidse of the heart is felt, and indeed seen, be- 
tween the fifth and sixth ribs, and a little exterior to the line of the 
left nipple ; but the point where it strikes the chest varies a good 
deal, simply by a change of position. Mr. Sibson gives a striking 
illustration of this fact in the case of an adult male. When the 
" man lay upon his back, the impulse of the apex was felt between 



ABNORMAL IMPULSE OF THE HEART. 325 

the fourth and fifth ribs, just below the nipple; the fifth rib was 
slightly heaved up. When he lay on the left side, the apex was 
felt beating strongly between the fifth and sixth ribs, an inch or 
more to the left of the nipple. When on the right side, the im- 
pulse of the apex could not be felt : there was a gentle heaving of 
the lower part of the sternum. When he lay on his abdomen, the 
apex was felt to beat over the third and fourth intercostal spaces. 
When he sat up, the apex descended from the fourth to the fifth 
intercostal space." Dr. Stokes has, more precisely than any one 
else, pointed out the occasions of displacement of the heart by dis- 
ease. He has seen it thrust down from the fourth to the eighth rib 
in a case of bronchitis. The most frequent cause of its displace- 
ment is effusion into the left pleura, by which the heart is some- 
times thrust entirely to the right of the mesial line of the sternum. 
More rarely, effusion into the right pleura has been followed by a 
like displacement of the heart, but not until the decline of the dis- 
ease. The progressive contraction of the parts within the right 
side of the thorax has then drawn the mediastinum, and with it 
the pericardium and the heart, to that side, so that it could be felt 
pulsating distinctly between the right nipple and the sternum. 

The real, or apparent force of the heart's impulse depends on 
several circumstances. Thus in thin, narrow-chested persons, and 
in the young, it is very distinct ; but whatever adds to the thickness 
of the thoracic parieles, or interposes a non-sonorous body be- 
tween them and the heart, diminishes its impulse. Its impulse may 
be very feeble, or quite imperceptible, in very fat persons, and 
in those who have a capacious chest ; also when the subcutaneous 
cellular tissue is distended with air or serum, or when the lung, 
either in its natural condition or emphysematous, or an effusion into 
the pericardium, comes between the heart and the ribs. The same 
result may be induced by debility of the heart itself; this is con- 
stantly observed in petechial typhus and other low fevers, during 
convalescence from exhausting diseases, and in hemorrhage, pro- 
vided there be no nervous complication, for in that case the action 
of the heart maybe temporarily augmented. In persons of a ner- 
vous temperament, but otherwise healthy, the least mental emotion 
may, as is well known, throw the heart into such violent and irre- 

28 



326 SEMEIOLOGY. 

gular palpitations as to arrest its movements and produce syncope. 
Whatever tends to accelerate the circulation, and especially violent 
muscular action, may induce the same result. But palpitations 
arising under these circumstances are, in general, momentary, or 
they are at least not constant. Those, even, to which anemic and 
nervous females are subject, are more or less paroxysmal, and 
usually cease during complete repose. Permanent palpitations, on 
the other hand, which are never wholly quieted even by rest, are 
of much more serious significance, for they nearly always attend 
inflammatory or structural disease of the heart. 

Changes of structure in the heart and great vessels are unques- 
tionably the most ordinary causes of its permanently increased ac- 
tion, an action not always confined to the prsecordial region, but 
sometimes making the whole chest, head, and trunk, and even the 
patient's bed to shake. A patient once assured the writer that the 
palpitations of his heart, and the throbbing which attended them, 
were so violent as to raise his head from the pillow. The statement 
was of course exaggerated, but it serves to convey some idea of the 
energy which occasionally marks the arterial pulsations. These 
latter are not to be confounded with increased prsecordial impulse : 
they are entirely owing to augmented capacity and power of the 
left ventricle, or hypertrophy with dilatation, while it, as has been 
shown, depends upon auricular hypertrophy. One may exist quite 
independently of the other, although it is true that in a majority of 
cases of strong arterial pulsation, there is also strong praecordial 
impulse, because both auricle and ventricle are hypertrophied. 
The facts connected with this subject lend an important confirma- 
tion to the theory of the heart's impulse which has been advocated 
in the preceding pages. The force of the arterial pulse bears no 
fixed proportion to that of the heart, which it should do if they both 
depended upon the power with which the ventricle contracts. The 
pulse " bears strict relations in strength and size to the thickness and 
capacity of the left ventricle ;" but neither does the pulse nor the 
development of the left ventricle, bear a constant relation to the 
force of the heart's impulse. One reason why ventricular hyper- 
trophy has been so confidently and so generally asserted to be the 
cause of the praecordial impulse, is that this lesion has usually been 
found where the impulse was augmented : it was natural to regard 



THE SOUNDS OF THE HEART IN DISEASE. 327 

them in the relation of cause and effect. Observers had their 
theory of cardiac sounds and movements already settled, and in 
their dissections they too commonly neglected everything which 
had not some direct bearing upon this theory. Thus, Dr. Hope 
published about 22 fatal cases of organic disease of the heart, in 
his treatise, in 4 only of which is a single word said about the state 
of the auricles, and that little as if by accident. And yet this much- 
slighted appendage of the heart, which, according to the current 
theory, performs no office which the veins could not equally well 
fulfil, has been considered, by the Creator, of such importance that 
it is found not only in animals with double hearts, but throughout 
the whole range of vertebrated animals, and even amongst the in- 
vertebrated, in all indeed which possess a proper central organ of 
circulation. Such prominence and constancy in all the grades of 
animal organism bespeak for the auricle more consideration than 
it has hitherto received from physiologists and cultivators of 
pathology. 

The sounds of the heart are subject to numerous modifications 
which it is of the highest importance to be acquainted with. The 
points at which they are most distinctly heard may vary ; they 
may be audible in a greater or less extent ; they may be louder or 
feebler; the order of their succession may be changed, their tone 
altered, or other, and abnormal sounds, may take their place.* 

The points at which the sounds of the heart are most distinctly 
heard are changed through the influence of the same causes which 
affect the seat of the impulse, a part of which have already been 
enumerated. They are rarely heard at a lower than the normal 
place, unless the heart is thrust down by a tumour developed in the 
superior mediastinum; much more frequently they are heard at a 
higher point than natural, even at the third or second rib. in con- 
sequence of the diaphragm being pressed upwards by a large effu- 
sion in the abdominal cavity. Still oftener they are detected at 
some distance either to the right or left of the precordial region, 
owing to the displacement of the heart by gaseous or liquid effu- 

* For many of the succeeding- details relative to the physical signs of the 
heart and lungs, the writer is indebted to the excellent Treatise of MM. Barth 
and Roger. A translation of these authors' summary of their work has been 
made by Dr. F. G. Smith, of this city. 



328 SEMEIOLOGY. 

sions in one of the pleural cavities. Excessive hypertrophy and 
dilatation of the left ventricle may render the first sound audible at 
a point lower and more to the left than where it should be heard. 

The limits within which the cardiac sounds are audible, vary a 
good deal even in healthy persons, according to the natural energy 
of the heart, and the capacity of the individual's chest. They 
generally grow less and less distinct as they are listened to in the 
following regions, respectively : the left side of the chest anteriorly; 
the right side anteriorly ; the left and then the right side poste- 
riorly. They are more feeble than natural when the heart is af- 
fected with softening, muscular debility, auricular thinning, con- 
centric hypertrophy of the ventricle, or when fluid in the pericardium 
or an emphysematous lung deadens the sonorous vibrations. On 
the other hand they are more distinct whenever the heart acts with 
unwonted energy, whether from excitement of the nervous system, 
or from increased development of the organ itself, or when the 
lungs are solidified by disease, and thereby become better conductors 
of sound. Thus when either lung is hepatized, or infiltrated with 
tuberculous matter, the sounds are audible, even distinctly so, at 
points where, in health, the closest attention could not detect them. 
In tuberculization of the upper lobe of the right lung, the sounds are 
more distinct under the corresponding clavicle than under that of 
the left side. 

The rhythm of the sounds of the heart, that is the proportion 
which each one bears to the series of sounds and pauses which 
have been described, may be variously modified by disease. In- 
creased frequency of the heart's pulsations forms one of the princi- 
pal elements of fever, and its degree, in affections of an inflamma- 
tory type, is pretty accurately proportioned to the severity, extent, 
and danger of the lesion, and to the importance of the organ involv- 
ed. It is also met with in certain states of debility consequent upon 
anemia. But in all of these cases of general disease, the number 
of pulsations in a minute does not often exceed 160, at least in 
adults; if it reaches 170 or 180 it is one of the most unfailing 
signs that a fatal issue is at hand. In affections of the heart itself, 
however, its throbbings are so continuous, or irregular and tumul- 
tuous, that they cannot be counted, and the finger applied to an 
artery perceives only a quivering movement. The sudden occur- 



RHYTHM OF THE CARDIAC SOUNDS. 329 

rence of these symptoms in an individual whose heart had pre- 
viously acted with perfect regularity, is very justly regarded by 
MM. Barth and Roger as indicating the formation of a fibrinous 
clot within the central organ of the circulation. Unusual slowness 
of the heart's movements is much less frequently dependent upon 
disease affecting itself. It is chiefly met with in chronic softening 
and in tuberculous affections of the brain, and after the use of 
digitalis. 

The relative duration of the sounds and pauses may be altered. 
The first sound is most commonly affected, and its prolongation is 
usually ascribed to ventricular hypertrophy ; but of this the evi- 
dence is by no means conclusive. The greater or less rapidity of 
the heart's movements chiefly affects the duration of the pauses. 
Sometimes the pulsations are irregular: thus there may be five or 
six in as many seconds of time, and immediately afterwards double 
the number in an equal period. Or, again, the heart may stand 
still during the whole period of one of its revolutions, and then 
resume its regular beats. Such an intermission may occur at fixed 
intervals, every fifth, sixth, or tenth pulsation, for example. Hence 
the necessity in feeling the pulse to keep the finger upon it long 
enough to detect such irregularities, should any exist. Occasion- 
ally the second sound is wanting. This is chiefly confined to cases 
in which the action of the heart is so feeble that it hardly distends 
the arteries with blood, and consequently fails to produce the sound 
which depends for its formation upon their elasticity. In other and 
still more unusual instances, three and even four sounds are heard 
in the precordial region. The most plausible explanation that has 
been given of the last phenomenon is, that the two sides of the 
heart no longer act in unison, whence the sounds made by each are 
heard separately. These various modifications of the heart's 
rhythm are of very uncertain semeiological value. If they are un- 
combined with abnormal sounds they may commonly be referred 
to neuralgia, disorder of the nervous system generally, or anemia, 
otherwise they more usually indicate organic disease of the heart 
itself, and are consequently of more sinister meaning. 

The tone of the cardiac sounds may heroine graver or more 
acute than natural. The former change is commonly held to be 

28* 



330 SEMEIOLOGY. 

the result of thickening of the muscular walls of the heart ; the 
latter, of their attenuation, or of a diminution in the plasticity of 
the blood. The first sound is almost exclusively that which be- 
comes graver than natural, and the second most frequently assumes 
a shriller tone. The latter is one of the peculiar symptoms of 
anemia and chlorosis. 

Abnormal murmurs. — Besides the numerous changes in the 
order, frequency, and character of the sounds of the heart, which 
have been described, there are other auscultatory symptoms of the 
highest importance ; murmurs, which mask, or take the place of 
the natural sounds. These are divided into endocardial and exo- 
cardial, according as they are formed within the heart, or exterior 
to it, in the pericardium ; the first include the several varieties of the 
blowing murmurs, the second the friction sound properly so called, 
the creaking sound, &c. — The bloiving, or bellows' murmur is by 
far the most frequent of all the abnormal sounds, for besides hav- 
ing an independent existence, it is usually the first stage of the 
other and harsher murmurs. It may exist only for a definite pe- 
riod, when the cause producing it is capable of removal ; its dura- 
tion is very transitory in plethora, and when heard in certain fe- 
males at the menstrual period ; it may attend an attack of endo- 
carditis and disappear soon after its cure ; and in like manner cease 
upon recovery from anemia or chlorosis. On the other hand when 
uncombined with any of these temporary conditions, it may gra- 
dually be supplanted by a rougher and louder sound, audible over 
the heart alone, or also in the great vessels of the neck, and the 
epigastric region. Sometimes it comes on suddenly, and sometimes 
its increase is gradual and progressive. Generally, there is but one 
bellows' murmur, and then ir masks the first sound, while the se- 
cond retains its natural characters; or it is so much prolonged as to 
take the place of the second sound also. This prolongation, how- 
ever, is more apparent than real. There are, in reality, two mur- 
murs, one formed in the auriculo-ventricular, and the other in the 
aortic orifice, and which are so fused together as to give the sen- 
sation of one continuous sound. 

The mechanism of these abnormal sounds, the mode in which 
they are produced, is next to be explained. It is evident that what- 



MECHANISM OF ABNORMAL MURMURS. 331 

ever tends to increase beyond a certain point the friction of a given 
quantity of blood against the edges of the openings through which 
it has to pass must produce sound. In the natural state of the 
organ, there is a just proportion maintained between the quantity 
of blood propelled and the orifice it traverses ; but when any of 
the cardiac orifices are contracted, this proportion is destroyed, the 
current of blood is subjected to unwonted friction by the hard and 
inextensible edges of the orifices, and vibration with sound results. 
The same effect should, of course, be produced if the contraction 
in question exists, not in the direction of the natural current of the 
blood, but as a deficiency in a valve, permitting regurgitation into 
the cavity which the blood has just left : and equally so when, al- 
though the orifices remain natural, an augmented quantity of blood 
is projected through them with increased velocity at every systole, 
as when a cavity is at the same time dilated and hypertrophied, So 
that a bellows' murmur in the heart is possible whenever the natu- 
ral relations between the capacity and contractile force of the 
cavities, the size of the orifices, and the rate of the blood's move- 
ment are suspended or destroyed. 

Jt is only by keeping before the mind this law, that apparently 
exceptional cases can be explained, those, for instance, in which 
the lesions of the valves are found after death, without there hav- 
ing been any abnormal murmur in the heart during the lifetime of 
the patient, and those in which such murmurs have existed, but no 
lesion of the heart could be detected. The orifice may be con- 
tracted, but the quantity of blood diminished, or the heart weaken- 
ed; in this manner the abstraction of blood may cause the bellows' 
murmur to disappear for a time. In other cases the cavity may 
contract several times before expelling the whole of its contents, 
and then, the proportion being maintained between the amount of 
blood propelled and the diameter of the contracted orifice, no mur- 
mur may result, but several pulsations of the heart will be per- 
ceived, for one that can be felt in the arteries. In others, again, 
no unusual murmur is audible so long as the heart beats moderate- 
ly, either through the influence of rest or of sedative medicines, 
but produces more or less of the blowing sound when its action is 
augmented by exercise or by diifusible stimuli. 



332 SEMEIOLOGY. 

But independently of any valvular lesion, the condition of the 
blood influences the production of the bellows' sound. It has 
been asserted to exist in cases of plethora, but whether from a posi- 
tive increase in the quantity of the blood, or from that augmenta- 
tion in the proportion of its red globules which Andral has shown 
to exist in this affection, or from what other cause, it is not easy 
to decide. It is difficult to understand how this sound should arise 
from two opposite causes ; for it is said to accompany plethora, 
and nothing can be more certain than its common occurrence in 
anemia, chlorosis, pregnancy, and other disorders and states in 
which the proportion of sanguine globules is greatly diminished. 
If the quantity of blood in the vessels be held sufficient to account 
for the murmur in question, it may be objected lhat the same mode 
of reasoning would be inapplicable to those cases of anemia in 
which the amount of blood is certainly below the natural stand- 
ard, as, for example, when this state is the direct result of profuse 
hemorrhage. It cannot, therefore, be received as a demonstrable 
conclusion, that the mere quantity or a particular quality of the 
blood is capable of generating the bellows' sound. It is sufficient 
for practical purposes to know that this murmur, so far as it de<- 
pends upon the composition of the blood, is nearly always allied to 
a deficiency of the red globules. When detected in any case, the 
observer can be at no loss to decide, from the general symptoms, 
whether it depends upon plethora or the opposite condition, the 
only difficulty consists in distinguishing it from the analogous mur- 
mur occurring in the first stages of valvular disease. 

In relation to the rasping, filing, and salving, or harsh mur- 
murs, their physical causes are essentially the same as those of 
the blowing sound which has been discussed ; their peculiarities 
are supposed to depend upon the greater force with which the 
blood is propelled through the heart, and the greater roughness of 
the edges of the cardiac orifices, and to be more distinctly marked in 
proportion as these conditions are more strongly developed. When 
these murmurs exist in their highest degree, and particularly when 
they are formed in the aortic orifice, they give rise to a tremulous 
motion of the prsecordium, readily felt on applying the hand, and 
which, from its resemblance to the sensation experienced on caress- 



SIGNS FROM CARDIAC MURMURS. 333 

ing a purring cat, has been aptly termed the purring tremour. 
Certain musical sounds, resembling the cooing of a dove, the dis- 
tant whining of a dog, &c., are sometimes heard in disease of the 
heart. These sounds are regarded as identical with those already 
described, except that they are in a higher key, for they have in 
nearly every instance been found to coincide with similar lesions 
of the valves and orifices. In exceptional cases, no lesion what- 
ever of these parts could be found to account for them. 

Semeiology of Cardiac Murmurs. — Since it must now be ad- 
mitted that the bellows' murmur, variously modified, may exist in 
numerous and very dissimilar affections, the question naturally 
presents itself, are there any circumstances accompanying this 
murmur which give it a definite value as a sign of cardiac disease? 
Upon what grounds must the opinion be based that it depends upon 
a structural lesion of the heart, upon an alteration of the blood, or 
upon some other cause? To answer these and similar questions, 
it becomes necessary to consider in succession and conjointly, the 
tone of the murmur, its coincidence with either of the natural 
sounds and pauses of the heart, its duration, its progress, and the 
other symptoms with which it is allied. 

As regards the tone of cardiac murmurs, it may be remarked 
that when soft and breath-like, without partaking at all, or only at 
intervals, of the harsher characters, it usually depends upon a 
mere imperfection of the valvular apparatus, or the simple narrow- 
ing of an orifice without roughness, or else upon an alteration of 
the blood or nervous over-excitement of the heart. If, on the other 
hand, the murmur is harsh, and that permanently, there is but 
little doubt of its resulting from an obstacle of irregular form in 
the current of the blood, a lesion of a valve or orifice, for in- 
stance. 

The occurrence of an abnormal murmur simultaneously with 
the first or second sound is a valuable element of diagnosis. 
Thus, a murmur which is independent of structural lesion in the 
heart is uniformly coincident with the first sound, and one which 
is heard with the second sound only, depends almost invariably 
upon a deficiency in the semilunar valves of the aorta. But a 
murmur of harsh tone, and audible during the first sound alone, 



334 SEMEIOLOGY. 

may be generated either at the auriculo-ventricular, or at the 
aortic orifice ; the exact locality of the lesion producing it must 
be inferred from other considerations. 

The signification of the longer or shorter continuance of a mur- 
mur, as regards its dependence upon structural lesion or other 
causes, and that of its progress from a softer to a harsher tone, 
have already been pointed out. Permanence and harshness are 
the two chief characteristics of valvular murmurs. The concomi- 
tant symptoms call for especial attention in every suspected case 
of heart disease. In addition to the existence of a murmur, the 
other local and general signs of cardiac disease should be sought 
for, such as extensive dulness on percussion, purring tremour, alte- 
rations in the rhythm of the heart's movements and sounds, irregu- 
larity of the pulse, marked oedema of the ankles, &c, symptoms 
which, taken collectively, are never met with in functional dis- 
orders of the heart. 

But when it has been fully ascertained that the structure of the 
heart is changed, the question still remains to be settled, What is 
the seat and character of the lesion ? It is admitted by all com- 
petent authorities that a murmur taking the place of, or obscuring, 
the second sound, is due to an imperfection of the semilunar valves, 
which allows the blood to regurgitate from the artery into the ven- 
tricle ; but some of them, reasoning from an erroneous theory, 
rather than drawing their conclusion from facts, maintain that the 
murmur in question may also be owing to contraction of the 
auriculo-ventricular orifice. This notion is sufficiently refuted by 
the fact that there is no case on record of a murmur in the second 
sound with no other lesion of the heart than narrowing of the 
auriculo-ventricular orifice; on the contrary, it is the uniform re- 
sult of observation, that when such narrowing is accompanied with 
a murmur, it coincides with the first sound of the heart, or rather 
precedes it a little. But a murmur accompanying the first sound 
has also been found to coexist with two other forms of valvular 
disease, viz. imperfection of the auriculo-ventricular (mitral or tri- 
cuspid) valve, and narrowing of the aortic orifice by adhesion be- 
tween the semilunar valves. Here is to be found a strong con- 
firmation of the theory which has been adopted in the preceding 



SIGNS FROM CARDIAC MURMURS. 335 

pages. According to that theory, the first sound of the heart coin- 
cides with the systole of the auricle, the diastole, and then the sys- 
tole of the ventricle, so that if either the orifice by which the blood 
enters, or that by which it leaves the latter cavity, is narrowed, a 
murmur may ensue; and the same result takes place if the auri- 
culo-ventricular valve performs its office incompletely, and allows 
blood to regurgitate into the auricle during the systole of the ven- 
tricle. It is characteristic of the murmur produced by the cause 
last mentioned, that it is soft. Such might, indeed, be anticipated 
as its character ; for if the arterial orifice is free, the blood which 
regurgitates into the auricle from the contracting ventricle must be 
small in quantity, and urged with but a moderate force. 

If, then, a harsh murmur is heard during, or immediately pre- 
ceding or following, the first sound of the heart, it must be due to 
contraction either of the auriculo-ventricular, or of the arterial 
orifice ; and the only remaining question is, in which of them it is 
formed ? When heard at the commencement of the first sound, 
and most distinctly near the apex of the heart, it is caused by an 
obstacle to the passage of the blood from the auricle into the ven- 
tricle ; but when audible towards the termination of the first sound, 
and opposite the junction of the third ribs with the sternum, it is 
produced by a narrowing of the arterial orifice. 

It must not, however, be supposed, because the murmurs when 
heard are referrible to the several lesions which have been enu- 
merated, that these lesions necessarily occasion the murmurs, or 
that all of them do so to the same extent. It has already been 
insisted upon, that a disproportion between the diameter of the 
several orifices, the size of the column of blood traversing them, 
and the force with which that blood is propelled, is essential to the 
production of morbid murmurs. Hence, although an orifice may 
be greatly narrowed, if the walls of the cavity behind it are com- 
paratively feeble, no murmur will result from the passage of blood 
through the contracted opening. On this account it is, most pro- 
bably, that contraction of the semilunar valves is much more con- 
stantly attended with abnormal murmurs than that of the auriculo- 
ventricular orifice ; for the power driving the blood through the 
former, (the systole of the ventricle,) is much greater than the 



336 SEMEIOLOGY. 

power which propels the blood through the latter, namely, the sys- 
tole of the auricle. But, whether the explanation be correct or not, 
the fact cannot be gainsayed, that the abnormal murmur is much 
more frequently wanting in mitral than in aortic contraction. MM. 
Barth and Roger even allege that, if a patient presents general 
symptoms of organic disease of the heart, such as disorder of the 
circulation, palpitation, dyspnoea, a contracted pulse, and oedema 
of the lower extremities, the absence of a murmur in the heart 
ought not to be held as conclusive against admitting the existence 
of valvular disease ; and that they have, more than once, under 
these circumstances, asserted the auriculo-ventricular orifice to be 
narrowed, and had their judgment confirmed by subsequent dissec- 
tion. 

When it has been satisfactorily determined to what lesion and 
to what orifice an abnormal murmur is to be referred, it must still 
be ascertained which side of the heart is the seat of disease. And, 
in the first place, in the absence of any definite signs, it must be 
remembered that lesions of the left side of the heart are far more 
frequent than those of the right, and the presumption is conse- 
quently in favour of the former. Again, in valvular lesions of the 
left side, whether by contraction or imperfection, the arterial pulse 
is affected, having, when there is a defect of substance in the semi- 
lunar valves, a characteristic jerking movement, and in the other 
valvular alterations a smaller volume than natural ; while in val- 
vular lesions of the right side, the obstacle to the regular passage 
of the blood is mainly shown by pulsation, or at least turgescence, 
of the jugular veins. In addition to these marks, there is another 
which may facilitate the diagnosis, and which is derived from the 
fact that the normal sounds of the heart are audible to a greater 
distance than such as are the consequence of disease. On apply- 
ing the ear to the chest, about the level of the heart, and at points 
gradually receding from it, both on the right and the left side, it is 
evident that the side on which the morbid murmurs first cease to 
be heard, while the normal sounds remain distinct, is the healthy 
side. Thus, in the most common case, valvular disease of the left 
side, as the ear recedes towards the right nipple, it will reach a 
point at which the murmur becomes inaudible, although the tictac 



SUMMARY OF ENDOCARDIAL SIGNS. 337 

of the uninjured side can still be heard. This method is not appli- 
cable to the diagnosis of lesions of the pulmonary artery and aorta, 
on account of the proximity of these vessels, and their relative 
situation — the one being behind the other; nor is it to be depended 
upon, unless the lungs are healthy : for the solidification of one of 
these organs may cause a murmur to be heard at a more distant 
point than the normal sound of the opposite side of the heart. 

The simpler instances of cardiac murmurs have been now con- 
sidered. The rules laid down for their detection, are the only 
guides which exist for analyzing those complicated cases in which 
three, and even four, abnormal murmurs are generated in the same 
heart ; as when the valves, which guard both orifices of the ventricle, 
are at the same time adherent, so as to impede the passage of blood, 
and defective, so as to permit its regurgitation. It must be admitted, 
that success in unravelling so intricate a combination of murmurs, 
is chiefly to be coveted as an evidence that the skill of the observer 
is not likely to be at fault in simpler cases. 

The following is a concise summary of the semeiological values 
of the different endocardial murmurs : 

1st. A soft, irregular, or intermittent bellows' murmur, accom- 
panying or masking the first sound of the heart, and existing with- 
out any symptoms of inflammatory or organic disease, should be at- 
tributed either to an alteration of the blood, or to irregular nervous 
action. 

2d. A gentle but regular murmur with the first sound, may be 
owing to the formation of soft exudations on the valves, as in rheu- 
matic endocarditis ; or, possibly, to the mere inspissation of the 
blood by fibrin, in febrile affections ; or, when permanent, to insuf- 
ficiency of the auriculo-ventricular valves. 

3d. A permanently harsh murmur indicates organic lesion of 
an orifice or valve. 

4th. A murmur in the second sound is invariably a sign of per- 
manent opening of the aortic valves, permitting regurgitation. 

5th. A more or less harsh murmur preceding the first sound, 
and most audible at the apex of the heart, is a sign of auriculo- 
ventricular contraction. 

6th. A soft murmur, audible at the close of the first sound, and 

29 



338 SEMEIOLOGY. 

near the apex of the heart, indicates permanent opening of the au- 
riculo-ventricular orifice, permitting regurgitation to take place into 
the auricle. 

7th. A harsh murmur, commencing at or near the close of the 
first sound, and most plainly heard at the upper part of the sternum, 
denotes contraction of the arterial orifice. 

8th. In the present state of our knowledge, organic affections of 
the right, cannot be, with absolute certainty, distinguished from 
those of the left side of the heart. The former chiefly disturb the 
venous, the latter the arterial system ; and the murmurs caused by 
the lesions of the left side, are not audible so far to the right of the 
sternum as are the normal sounds of the right side of the heart, 
and vice versa. 

Exocardial murmurs. — These, which are symptoms of one dis- 
ease only, pericarditis, vary in strength and tone, and, according 
to Dr. Hope, result " from attrition of the opposite surfaces of the 
pericardium roughened by lymph, and also in some cases from the 
roughened surfaces agitating or churning a little serum between 
them." They have generally a rough, rustling, or grating charac- 
ter, sometimes a creaking tone like that of new sole-leather, and 
again a rumbling or churning sound. The exocardial murmurs 
are generally double, coinciding with both sounds, or with both the 
diastole and systole of the ventricle, but are always most distinct 
during the first sound ; they are occasionally however heard during 
this sound alone, less frequently alor>g with the second, and some- 
times even in the interval between the two.* The friction sound of 
pericarditis seems to be formed closer to the surface than the endo- 
cardial murmurs. It may be audible either in a very narrow 
space, or throughout the whole precordial region, but is always 
most distinct near the apex of the heart. 

This attrition murmur may assume several, or most of the cha- 
racters, above described, during the progress of the same case. 
It is usually mild at the commencement, and if an effusion of serum 
take place into the pericardium separating the two serous surfaces 
from one another, it ceases to be heard altogether; it is again au- 

* Dr. Sargent, of this city, informs the writer that in a case of pleurisy 
of the left side, he has heard, while the patient held his breath, a friction- 
sound which was evidently caused by the movements of the heart. 



ENDOCARDIAL MURMURS THE PULSE. 339 

dible when the effusion is so far reduced as to allow the opposite 
false membranes to come into contact with one another, and once 
more ceases when adhesions are formed between these membranes. 
It is believed to acquire a harsher tone in proportion to the rough- 
ness and dryness of the false membranes. 

Signs from the arteries. — These may be studied under two 
heads, 1st, the characters of the pulse; and 2d, auscultation of the 
arteries. 

The pulse. — In entering upon this subject, it may be well to 
guard against a misapprehension very generally entertained. We 
hear constantly of an arterial wave, of a wave of blood, &c, as if 
the arteries and veins were half-filled canals. These vessels are 
always full, and may be fitly represented by an elastic tube bent in 
the form of a circle, so that a movement communicated to any one 
portion of the fluid contained in it is propagated to all the other 
portions. If the blood-vessels were not elastic, for every ventricle 
full of blood thrown into the aorta a precisely equal quantity would 
be poured from the vense cavse into the right auricle, and at the 
same intervals of time. There would, moreover, be a venous as 
well as an arterial pulse, and both produced by the same cause. 
Although the blood-vessels are elastic, the momentum given to the 
blood in the aorta is not the less propagated to that in the large 
veins, but the elasticity of the vessels, a constant force maintained 
in activity by the intermittent action of the left ventricle, intervenes 
between that ventricle and the veins, and in them substitutes a 
continuous for what would else be an interrupted current. Just as, 
in an ordinary fire-engine, the intermittent action of the piston pro- 
duces a continuous stream from the branch-pipe through the inter- 
vention of the air-chamber. In the latter case the agent effecting 
this object is the elasticity of the air within an inextensible cavity ; 
in the former, it is the inherent power of extension and contraction ? 
i. e. the elasticity, of the walls of the cavity itself. 

Now, because the arteries are elastic they are always full ; they 
enlarge and diminish in size according to the amount of blood thev 
have to transmit. But this elasticity is limited in both directions; 
they cannot be stretched beyond certain limits without bursting, 
nor on the other hand contract so as wholly to obliterate their 
cavities. The more distended thev are the harder thev will feel: 



340 SEMEIOLOGY. 

the less distended, the softer. But the distending cause, the systole 
of the ventricle, acts at intervals, so that the degree of arterial 
hardness, or resistance to pressure, can only be measured at the 
moment of the ventricular systole. If the latter cease, the elasticity 
of the vessel at once acts without opposition, and the artery con- 
tracts as far as possible upon its contained blood, which flows into 
the more extensible veins. Hence, it is plain that hardness and 
fulness of the pulse depend not only en the amount of blood in the 
artery, but also upon the force with which that blood is propelled 
by the ventricle. The manner in which this cavity contracts, gives 
to the pulse many of its peculiarities ; the power of the one is pretty- 
fairly indicated by the force of the other, so long as the circulating 
fluid is equably diffused. But if a large portion of the blood in the 
body gorge the liver, the lungs, the spleen, or any other parenchy- 
matous structure, that portion may be regarded as temporarily with- 
drawn from the blood-vessels. In this way chiefly, must be ex- 
plained the small and feeble pulse which is observed in the cold 
stage of intermittents, and other internal congestions. The quantity 
of blood in the body is by no means, therefore, to be estimated by 
the pulse alone, unless this fluid is diffused in due proportion to the 
several parts of the system. 

The physical cause of the pulse is indeed, as was stated, the 
systole of the ventricle, but the apparent force of the arterial pulsa- 
tion is very much augmented by the pressure made upon it by the 
finger. The finger partially obstructs the calibre of the vessel, and 
therefore receives a smart blow from the column of liquid behind 
the obstruction, and at the same time perceives the rapid flow of 
the blood through its narrowed channel. This consideration should 
induce caution in estimating the force of the pulse. 

The mode of examining the pulse has been pointed out in a pre- 
vious chapter. This examination should be made towards the close 
of the physician's visit, as well as at its commencement, in order 
that the patient may have time to recover from the agitation which 
he usually experiences on such occasions; it should, also, when 
two visits a day are paid, be made both morning and evening, for 
the diurnal changes of the pulse are often considerable in disease. 
The number of the pulsations in a minute, their force and rhythm, 
and their modification under pressure being ascertained, it is well 



VARIETIES OF THE NATURAL PULSE. 341 

to note the influence of the sitting posture, of accidental excitement 
of mind, &c, upon its frequency, regularity and other characters. 
The pulse at both wrists, and sometimes that of the carotids, ought 
to be felt, for an abnormal distribution of the radial artery, its 
partial ossification, or obstruction, may lead into serious error. 
The writer had under his care a young woman who was subject to 
hysterical paroxysms, and whose pulse presented a curious phe- 
nomenon. The pulsations of the left radial artery were generally 
imperceptible, or very feeble, while those of the right side were 
proportioned to the activity of the heart. At the same time a dis- 
tant blowing sound was to be heard under the left clavicle. Oc- 
casionally, however, this sound became inaudible, and the artery 
of the left arm pulsated almost as fully as the corresponding one 
of the opposite side. No satisfactory explanation of this singular 
state was ever obtained ; the patient ultimately recovered her 
health. 

Varieties of the pulse consistent ivith health. — Age, sex, tem- 
perament, exercise, sleep, food, &c, exert considerable influence 
upon the condition of the pulse, and must be known before any 
just inference can be made from its condition in disease. 

The frequency of the pulse in infancy has been very diversely 
stated by different authors. Since the more accurate observations 
of later years have been made, it may be adopted as a general rule, 
that the pulse increases in frequency from the period of birth to 
the fifth month, when it becomes gradually slower until the close 
of the second year, and continues at nearly the same point until 
the approach of the second dentition. During all this time, how- 
ever, the variations of the pulse run through so wide a range, and 
are due to such slight causes, that its frequency is of little or no 
value as a symptom of disease, when unaccompnnied by heat of 
skin and other general symptoms. Thus M. Trousseau has shown, 
that during the first two weeks of life, it varies from 78 to 150 ; in 
the second half of the first month, from 129 to 164; between one 
and two months, from 96 to 132; between two and six months, 
from 100 to 162 ; between six months and one year, from 100 to 
160; between one year and twenty-one months, from 96 to 140. 
These higher numbers appear to have been due to the influence of 

29* 



342 SEMEIOLOGY. 

the waking state, of muscular exertion, of heat, of temper, &c, for 
when the pulse of infants has been examined during their sleep, its 
average has been shown by M. Valleix to be considerably below 
that of the observations last named. M. Valleix gives the average 
during the first six months after birth as between 90 and 100. He 
also confirms the statement of other writers, that sleep renders the 
pulse slower, and that it is a good deal more frequent in female 
than in male infants. From the seventh to the twenty-seventh 
month, he finds the average frequency of the pulse nearly uniform, 
or about 126. 

Between the ages of two and seven years, the pulse is somewhat 
over 100, and after that period continues to grow less frequent 
until it reaches the adult standard, or about 70. In old age, it 
again becomes somewhat more frequent, contrary to the prevalent 
belief upon this subject, according to which, after adult life the fre- 
quency of the pulse gradually declines. Dr. Pennock, of this city, 
has published (Am. Jour, of Med. Sci., July, 1847) an account of 
a series of very interesting and accurate observations made by him 
upon this subject, from which it appears, that in 170 men whose 
average age was 64*09 years the medium pulse was 71*83 per 
minute; and that in 203 females, whose average age was 70*57 
years, the medium pulse was 78*02 per minute. But Dr. Pennock 
did not find that the pulse became more frequent as old age ad- 
vanced, except within certain limits. Thus in males, between the 
ages of 50 and 60, the pulse was more frequent than at any sub- 
sequent age ; but that beginning at the age of 60, and going on to 
90, the frequency of the pulse gradually increased. In females, 
on the contrary, the frequency, of the pulse began to increase be- 
tween the ages of 50 and 60, and maintained that tendency till the 
age of 80, when it declined. It may, therefore, be laid down as a 
general proposition, that both in old age and infancy the pulse is 
more frequent than in adult life. 

Sex influences the character of the pulse. In females it is 
quicker, harder, smaller, and more frequent than in males, and is 
more liable to be affected by trifling causes. According to Dr. 
Guy, the pulse of women is more frequent by 10 or 15 per minute 
than the pulse of men. 



CAUSES MODIFYING THE PULSE. 343 

Persons of a sanguine tevnperament have generally a full, strong, 
and resisting pulse ; the lymphatic, on the other hand, a soft and 
compressible pulse; and the nervous a small, quick, and frequent 
pulse. In warm climates, and under the influence of heat gene- 
rally, the frequency of the pulse is augmented ; cold, on the other 
hand, renders it slower. Blumenbach relates, that the ordinary 
pulse of the Greenlanders does not exceed 30 to 40 per minute. 

Position modifies the pulse. In healthy and unexcited persons, 
Dr. Guy found that the pulse which was at 79 in the erect posture, 
fell to 70 in the sitting, and to 67 in the recumbent posture. The 
difference between the two extremes, as influenced by position, is 
always greatest when the patient is very weak. The acceleration 
of the pulse observed under these circumstances is, no doubt, 
owing to the muscular effort required to keep the trunk or the 
whole body erect, for it is found that all muscular exertion aug- 
ments the frequency of the pulse. Of this, Dr. Nick of Tubingen 
has furnished many illustrations. He states that dancing, for ex- 
ample, will raise the pulse from 75 to 124, and even 148. 

The same author confirms by his observations, the well-known 
fact, that the pulse is lowered by sleep, or rather during sleep by 
the cessation of muscular action and mental excitement, and by 
the recumbent posture. In regard to the diurnal variations of the 
pulse, observers are not agreed, some having found it more fre- 
quent in the morning, and others in the evening. Those who 
make the former statement, appear to have confined their experi- 
ments to selected cases, to healthy persons confined to bed, and 
examined while fasting. Amongst men placed in ordinary cir- 
cumstances, the acceleration of the pulse towards the close of the 
day cannot be called in question. 

Eating and drinking have a sensible influence on the frequency 
of the pulse. It is said to be accelerated by as many as 12 beats 
per minute after an ordinary meal, and to continue above the ave- 
rage standard during four or five hours. Warm food and drinks 
especially affect it, and amongst drinks, those which contain the 
largest proportion of alcohol. Water, in small quantities, has no 
perceptible effect on the pulse; but, when taken copiously, has a 
somewhat depressing influence. 



344 SEMEIOLOGY. 

In addition to the foregoing circumstances, the characters of the 
pulse peculiar to the individual should always be taken into ac- 
count. It is said that Napoleon's pulse was naturally weak, and 
beat but 40 times in a minute; Chomel mentions having witnessed 
a like degree of slowness of the pulse in a lady, and Whytt one 
whose ordinary pulsations were 120 per minute. Regular and 
irregular intermittence of the pulse are by no means uncommon 
during health. A case is narrated by a Dr. Bidart (Gaz. Med. de 
Paris) of a man who was under his notice for nearly twenty 
years, and in whom, after every second pulsation, there was a 
complete intermission of one beat. This condition had existed 
from infancy, and when the subject of it died his heart presented 
no lesion whatever. 

Of the Pulse in Disease. — A great many varieties of pulse are 
described by authors; Galen mentions thirty-six, and Bordeu con- 
ceived that there was a condition of the pulse peculiar to the disease 
of every organ of the body. Such refinements are neither founded 
in nature nor useful in practice. Whatever changes are effected 
in the arterial pulsation by disease, may all be included under two 
general divisions : 1st, changes of strength ; and 2d, changes of 
rhythm. 

The pulse is said to be strong, when it forces back the finger 
which is pressed upon it, and feeble, when it does not resist 
such pressure. The former variety is generally noticed in in- 
flammations of organs largely supplied with blood-vessels, as the 
lungs and liver, and is the more strongly marked in proportion to 
the degree of plethora of the patient. In plethoric individuals this 
state of the pulse is an ordinary^forerunner of hemorrhage. The 
feeble pulse is met with in nearly all diseases attended with ex- 
haustion, and is common in the diseases of children, old persons, 
and women. It is most common in affections of a typhoid cha- 
racter, or in those which in their advanced stages assume this type, 
in typhus, puerperal fever, phlegmonous erysipelas, gangrene, &c. 

The full pulse gives the sensation of the artery being larger than 
usual ; the small pulse, of its diameter being less. The pulse is 
full as well as strong in plethoric individuals ; it is simply full in 
those who are tall and thin. In disease, it occurs under all the 



THE PULSE IN DISEASE. 345 

circumstances in which the pulse is strong. Smallness df the pulse 
often depends upon narrowing of one of the orifices of the left side 
of the heart; it should therefore always suggest the propriety of exa- 
mining the heart. Before its connexion with this lesion was known, 
the small pulse was regarded as a sure sign of debility, and some- 
times led to a plan of treatment directly opposed to what was re- 
quired. This state of the pulse is generally observed in inflamma- 
tion of membranous parts within the abdomen, and particularly of 
the peritoneum, in which case it is combined with hardness. It is 
more common without the last-named quality in nervous affections, 
in chlorosis and anemia, and during violent paroxysms of pain. 
Under these circumstances, the artery may be so reduced in size as 
to feel like a mere thread beneath the finger ; this is the filiform 
pulse. The pulse is both small and feeble in most of the cases 
mentioned as characterized by debility of the circulation induced 
by excessive discharges of any kind, whenever, in other words, 
the amount of blood in the vessels is greatly reduced. It acquires 
these characters, also, when the blood is removed from the ordinary 
channels of the circulation, and accumulates internally, as in the 
cold stage of febrile diseases. Such a pulse is an unfavourable 
sign, unless it speedily assume more natural characters. 

The pulse is said to be hard, when its resistance to the finger is 
prolonged, or when it gives a sensation like the vibration of a tense 
cord ; and is termed soft, when it yields readily to pressure. The 
former condition, also known as the contracted pulse, is commonly 
met with in membranous inflammations and rheumatism, and often 
during the paroxysms of convulsive disorders. So long as the 
pulse retains its hardness, the activity of the inflammation is un- 
abated. The soft pulse exists in petechial typhus with such 
marked characters, that the artery appears to be distended with 
air, and not with a liquid; it is full, and yet the slightest pressure 
arrests it. The pulse after exhausting discharges is soft, but is 
usually small and feeble at the same time. 

Quick and sloiv are terms used to describe a pulse in which the 
stroke is either given sharply, with a fillip, as it were, or else with 
a prolonged and deliberate movement. A pulse may therefore be 



346 SEMEIOLOGY. 

quick without being frequent ; but the two characters are very- 
general ly united. 

The most important modification of the rhythm of the pulse 
consists in its increased frequency, i. e. in its beating more fre- 
quently than usual in a given space of time. To measure with ac- 
curacy the degree of its frequency, a watch furnished with a second- 
hand should be used. It is customary to count the pulsations dur- 
ing a quarter of a minute only, and after a short interval to count 
them again ; in this way the second estimate serves to correct the 
errors of the first. When the pulse is beating very rapidly, it is best 
not to count beyond ten, noting the number of seconds required for 
that purpose, and renewing the count until a quarter or half a minute 
has elapsed. The advantage of this plan is, that having to name, 
or think of, numbers expressed by words of one syllable only, the 
operation is more rapidly performed than when the dissyllabic 
numbers above ten are employed. Chomel states that in this 
manner he has succeeded in counting 180 and even 200 pulsations 
in a minute. 

Acceleration of the pulse is the common symptom of all febrile 
disorders ; it augments with their increase, and subsides with their 
decline. It is generally proportioned to the heat of skin, and the 
frequency of the respiration. Its diminution is often one of the 
first signs of the decline of the disease. When the pulse continues 
to be frequent without appreciable cause, although the other symp- 
toms appear to improve, no permanent amelioration is to be anti- 
cipated ; either the original disease will resume its course, or some 
intercurrent complication be developed. When this* acceleration 
occurs at regular intervals, it forms one, and a principal, sign that 
the attack is assuming a remittent type, and is therefore of para- 
mount consequence in relation to treatment ; but if it take place in 
the evening, it is rather an evidence of hectic fever, and must be 
regarded as an unfavourable sign ; and particularly so, if preceded 
by chilliness, and followed by perspiration. It is difficult to fix 
any point above which the number of pulsations ought to be re- 
garded as febrile; for the state of nervous excitability which exists 
during the decline of many acute affections renders the pulse fre- 
quent and the skin slightly warm ; and in order to prevent these 



ALTERED RHYTHM OF THE PULSE. 347 

effects, nutritious food is often required, instead of sedatives and 
abstinence. In adults, the pulse rarely exceeds 120 per minute, 
even in pneumonia, which, more than any other inflammatory 
affection, increases the frequency of the pulse. The pulse of an 
adult above 150 in a minute, is one of the most unequivocal signs 
of a fatal issue. 

An infrequent or slow pulse is an ordinary symptom of diseases 
attended with coma, when this results from concussion, compres- 
sion, or other disturbance of the brain. It is one of the earliest 
and most certain signs of tubercular meningitis ; ii is occasionally 
observed in diseases of the heart, and after profuse hemorrhage. 
Several cases are reported of the diseases mentioned in which the 
pulse fell to 25 per minute. It should be remembered that this 
state of the pulse may be produced by an over-dose of digitalis. 

The pulse may be called irregular, either from a want of uni- 
formity in the intervals between the beats, or from inequality in 
the strength, fulness, quickness, or hardness of the successive pul- 
sations. Irregularity may be confined to the pulse of one side of 
the body. Albers, of Bonn, declares that in certain cases of ner- 
vous disorder he has found five or six pulsations more upon one 
.side than the other. This phenomenon is wholly irreconcilable 
with the only theory of the pulse which is in the least credible. 

The dicrotic pulse is that in which the finger is struck twice at 
each pulsation; or, rather, in which the pulsations succeed one 
another in pairs. The ancients regarded it as a precursor of he- 
morrhage ; an opinion, to some extent, confirmed by modern obser- 
vation. The intermittent, another variety of the irregular pulse, 
is so called from the omission of a beat at intervals, which are 
sometimes perfectly uniform. As already stated, such irregularity 
is by no means inconsistent with perfect health ; nevertheless, it is 
more commonly an indication of disease of the heart. It occurs, 
however, in other affections: in pericarditis, in large pleural effu- 
sions, and whenever the freedom of the circulation or of the respi- 
ration is interfered with. In connexion with the last-mentioned 
symptoms alone, can it be considered an unequivocally dangerous 
sign. 

In general, the pulse presents more than one of the characters 



348 S E 31 E I O L O G Y. 

which have been described. In plethora, and in febrile and inflam- 
matory diseases, the pulse is frequent, full, strong, and hard. In 
the collapse which often attends suppuration and disorganization of 
internal parts, the pulse is small, weak, and soft, and often irregu- 
lar and intermittent. In syncope it has these characters. The jerk- 
ing pulse, which is at once quick, hard, and strong, and ceases ab- 
ruptly, is regarded by Hope, and many other good observers, to be 
characteristic of a deficiency of the semilunar valves of the aorta. 
It is alleged that, in abdominal inflammations, the pulse is com- 
monly small, quick, and hard ; while in those occurring above the 
diaphragm, it is usually full and strong. The statement is pro- 
bably correct, so far as regards intestinal and peritoneal phlogoses 
on the one hand, and inflammations of the lungs and pleura upon 
the other. In most acute diseases, it may be stated, as a general 
rule, that the pulse is frequent, quick, and strong, during the active 
stage ; and at the height of the attack, fuller and softer, without being 
less frequent. During the decline, it is less frequent, slower, and 
softer, if convalescence is approaching, but more tense and frequent 
if suppuration threaten; weaker and smaller, if gangrene be about 
to take place; soft, feeble, and irregular, if the attack assume a 
typhoid character ; and, finally, if after being frequent, full, and 
hard, it should become sharp and small, without signs of collapse, 
there is reason to apprehend that the disorder will become chronic. 

The preceding remarks are believed to embody the most impor- 
tant facts of the present subject. The art of interpreting the pulse 
is still very imperfect. The movement of the circulation is sub- 
ject to so many variations from inappreciable, or extremely slight 
causes, that it would be very unwise for a practitioner to ground 
his opinion of the nature or probable issue of a disease, upon the 
characters of the pulse alone. It is more than probable that those 
who have attached most importance to its presumed indications, 
have, in reality, formed their judgment from the concomitant symp- 
toms, as well as from the pulse ; for, if it were otherwise, their 
precepts in diagnosis and prognosis, alleged to be founded upon 
this symptom alone, would not have been so generally contradicted 
by the experience of other observers. 

Signs from auscultation of the arteries. — When the stethoscope 



AUSCULTATION OF THE ARTERIES. 349 

is applied over an artery, in a healthy person, a peculiar, dull, 
short sound is heard, varying with the size of the vessel, its dis- 
tance from the heart, the thickness of its coats, and the quantity, 
quality, and velocity of the circulating fluid. In the thoracic aorta 
and the carotids, a double sound is perceived, which appears to be 
merely the reverberation of the normal sounds of the heart. Else- 
where, the sound in question is generally attributed to the shock of 
the blood against the walls of the artery. But there are two capi- 
tal objections to this explanation. In the first place, the sound 
generated by the passage of a fluid through a tube is prolonged ; 
it continues as long as the liquid moves with a certain velocity, and 
is not, as in the present instance, a momentary and abrupt sound, 
resembling that produced by a slight blow with the end of the fin- 
ger. It is certain, also, that when the artery is in a condition 
favourable to the generation of sound by its contained blood, as 
when its interior surface is roughened, a murmur of a very diffe- 
rent sort from that made in a healthy artery is heard ; it is one of 
equal duration with the first sound of the heart. In the second 
place, if it be said that the normal arterial sound is due to the late- 
ral shock of the blood during the diastole of the artery, it may be 
asked, how can such a shock take place in a vessel which is con- 
stantly full? It is not easy to conceive how the sudden distention 
of a tube can produce sound, unless it throw into vibration some- 
thing external to itself, either the air, or some solid body. This 
condition undoubtedly exists at the moment of the arterial diastole; 
the vessel strikes against the muscles, or other firm parts in con- 
tact with it, and may thus produce the normal sound of the artery. 
But we are disposed to question the probability even of this expla- 
nation ; it may be true, but it is not sufficient. We have again and 
again brought the stethoscope within a hair's-breadth of a large 
artery, without being able to distinguish the slightest sound ; but one 
became audible the moment the instrument was placed near enough 
to the vessel to receive its impulse, and appeared to be entirely due 
to the blow received by the stethoscope. For these reasons, we 
feel compelled to dissent from the prevalent doctrine, and to doubt 
the reality of the alleged arterial sound, so long as the vessels, ami 

30 



350 SEMEIOLOGY. 

the composition and velocity of the blood deviate in no respect from 
their condition in health. 

But, whatever may be the truth as regards the existence or the 
theory of the so-called normal sound, it is certain that abnormal 
arterial murmurs are generated by a diiferent mechanism, if the 
stethoscope be pressed upon an artery so as to diminish its channel, 
a blowing or bellows' murmur results. The sound thus produced 
artificially and at will, is identical with that heard under several 
morbid conditions, and may be generated by any cause which ex- 
cites unusual vibrations in the walls of the arteries. Such cause 
may be the increased force and rapidity of the heart's contraction, 
the consistence of the blood remaining the same, or being in- 
creased, as in plethora ; diminished consistence of the circulating 
fluid, as in anemia ; roughness or irregularity of the lining mem- 
brane of an artery ; or valvular disease, especially disease of the 
semilunar valves, of the left side of the heart. When the cause 
of this murmur is one affecting the whole circulatory system, either 
through disease of its central organ, or an alteration of the blood, 
it is more frequently audible in the vessels of the right, than of the 
left side ; a fact which must be admitted as the result of observa- 
tion, but which, in the present state of our knowledge, cannot be 
explained. It is more frequently met with in females than in males, 
because its most ordinary cause (anemia) is an affection to which 
the former are peculiarly subject. 

The bellows' murmur of the arteries may assume any of the 
characters described as belonging to the corresponding cardiac 
murmur, being soft or harsh, single or double. The morbid sounds 
heard in ausculting the aorta are sometimes entirely transmitted 
from the heart, sometimes generated in the vessel, and sometimes 
result from both of these causes combined. They accompany 
lesions of the aortic orifice, and pseudo-membranous, cartilaginous, 
and atheromatous degenerations and erosions of the internal sur- 
face of this artery, contraction of its calibre, simple dilatations and 
aneurisms, and communications of the aorta with an adjacent vein, 
forming varicose aneurism. 

When there is simple contraction of the aortic valves, the mur- 
mur is heard along with the first sound of the heart ; deficiencv of 



THE bellows' murmur. 351 

these valves is accompanied with an aortic murmur in the second 
sound of the heart, and when there is both contraction and defi- 
ciency, a double murmur is perceived. Unevenness of the internal 
surface of the aorta gives rise, in general, only to one murmur, 
corresponding to the first sound of the heart, and it is soft or harsh 
in proportion to the degree of roughness of the channel occupied 
by the blood. When the aorta is not only roughened but also di- 
lated, as in aneurism, the murmur is generally single, but in some 
instances double ; and in the latter case its second part is due 
either to the transmission of a morbid sound from the heart, or 
wholly to the reaction of the vessel upon the column of blood 
within it. The latter cause is, at the least, very problematical, for 
when the aneurism is remote from the heart — when it is seated in 
the abdominal aorta, for example, it gives rise to one murmur 
only. Tn varicose aneurism, which is an extremely rare disease, 
the interchange of currents between the vein and the artery occa- 
sions a continuous harsh murmur, resembling the sound produced 
by sawing. 

A harsh murmur confined to the line of the aorta, and heard at 
remote parts of this vessel, is nearly always owing to roughness 
of the inner face of the artery. In old persons, with ossified radial 
arteries, and in persons of any age who have long had valvular 
disease, this murmur indicates the existence of calcareous deposits ; 
but in cases where the murmur has suddenly appeared, along with 
high fever and oedema, acute inflammation of the aorta with for- 
mation of false membranes is most probable. 

A like murmur, strictly limited to a small space upon the front 
or back of the chest, without corresponding dulness on percussion, 
is indicative of roughness or stricture of the aorta at that point, 
and particularly the latter, if the intercostal arteries above this level 
pulsate more actively than those below. 

When a double bellows' murmur is heard in the course of the 
aorta, it probably proceeds from an aneurism with a large cavity, 
especially if the purring tremour, dulness on percussion, and a 
strong impulsion exist at the same point. A double sound, re- 
sembling the normal sound of the heart, with signs of a tumour, is 
indicative of an aneurism with thick and solid walls. 



352 SEMEIOLOGY. 

A continuously whirring, or strong blowing murmur, which is 
not synchronous with the cardiac sounds, and heard at a point in 
the course of the aorta, where this vessel lies in contact with a 
large vein, or venous cavity, renders probable a communication 
between the arterial and venous systems. If deductions from cases 
which have been accurately observed, are sufficient to establish a 
special diagnosis, it may be presumed that when this murmur is 
heard near the right side of the sternum and the second intercos- 
tal space, a communication exists between the aorta and the vena 
cava superior, or the right auricle ; when at a corresponding point 
on the left side, an opening from the aorta into the pulmonary 
artery, or the right ventricle, may be suspected. These probabi- 
lities acquire greater strength when the murmur has been de- 
tected after a severe pain in the part, and syncope, following 
excessive muscular exertion. The murmur in question, when 
heard in the course of the abdominal aorta, leaves but little 
doubt of the existence of a communication between the descend- 
ing vena cava and the aorta. 

A simple harsh murmur in the region last referred to, if ac- 
companied with a tumour which pulsates with a heaving or ex- 
pansive movement, denotes the existence of capacious aneurismal 
sac; if the tumour merely rise and fall with the diastole and 
systole of the artery, and continue to do so in all positions of 
the body, it is probably aneurismal, but nearly filled with fibri- 
nous layers; if, on the other hand, the murmur ceases when the 
position of the body is changed, or when the tumour is lifted 
from its seat, it is probably owing to some unnatural formation 
pressing upon the aorta. Finally, a bellows' murmur, if heard 
only at a fixed point, where no tumour exists, may be attributed 
to stricture of the aorta; for, if dependent upon an alteration of 
the blood, it would be audible in other arteries. 

Mere augmentation of the pulsatory movements of the abdo- 
minal aorta, without murmur or swelling, is to be referred to func- 
tional nervous disorder. These movements are sometimes so vio- 
lent as to raise the head of the stethoscopist forcibly, and to annoy 
and distress the patient exceedingly. They bear no proportion 
whatever to the decree of the heart's action. 



the bellows' murmur. 353 

The diagnostic si^ns which have now been enumerated as re- 
ferrible to disease of the aorta itself, are also to be met with, and 
have the same signification, in the secondary arteries. They have 
also the same origin, narrowing and roughness of the vessel at the 
points where they are heard, and are therefore to a great degree 
local. But, as was before hinted, there are other murmurs which 
may be audible throughout the entire arterial system, and which 
depend upon causes affecting the composition of the blood, or the 
velocity with which it moves. Of these important signs an ac- 
count will now be given. 

One of the murmurs produced by deficiency of the aortic valves 
belongs in part to this category, the one, namely, which corre- 
sponds with the first sound of the heart and with the pulse. In de- 
ficiency, without contraction, of these valves, there are two mur- 
murs ; but one only of them is very loud opposite the origin of the 
aorta, that which is formed by the regurgitation of the blood into 
the ventricle through the abnormal opening in the aortic valves; 
the other is most distinct in the arteries, and can sometimes be 
detected even in those of the lower extremities. The latter is 
formed where it is heard, and in the following manner : — The 
semilunar valves being perfectly supple, but not closing entirely 
the aortic orifice, the ventricle is obliged to propel not only the 
blood received by it from the auricle, but that also which returns 
into it from the aorta ; this additional quantity requires that the 
capacity of the ventricle should be increased for its reception, 
and the power of the ventricle augmented for its propulsion. 
Such, at least, seems to be the explanation of the dilatations 
and hypertrophy which affect the ventricle under the circum- 
stances referred to. The result of this change is, that at every 
systole of the ventricle, a larger amount of blood than natural 
is thrown with unwonted force into the arteries, augmenting the 
friction of this fluid in its channel, and generating a bellows' 
murmur. The insufficiency of the semilunar valves for the per- 
formance of their function is, therefore, not the direct, but the 
remote cause of the abnormal sound. This sound, like the 
others to be noticed, is never, unless some complication exist, 
of a harsh tone. It is strongest in the vessels nearest the heart, 

30* 



354 SEMEIOLOGY. 

in the carotids, for example, and decreases in the remoter arteries, 
because, as has well been suggested by M. Beau, the capacity 
of the arterial system becomes greater and greater as it recedes 
from the heart, and therefore the friction between the blood and 
the vessels, and the resulting sound must diminish in the same 
proportion. 

A bellows' murmur, it has been alleged by several authors, is 
audible in plethora, and they explain the supposed fact by assum- 
ing that in this state the heart acts with such augmented energy 
as to produce sonorous vibrations in the arteries or their contents. 
But it was not known, or was forgotten by these writers, that two 
opposite states of the blood might exist in plethora, one in which 
the blood is actually denser than natural, owing to the increase of its 
proportion of red globules, and the other in which this element of 
the fluid is diminished, although the vessels appear to be, and are, 
unusually full. The latter condition belongs to pregnancy, which 
is often accompanied with a soft blowing murmur in the arteries. 
If the term plethora be restricted, as it now is by some pathologists, 
to the former state, it is not, perhaps, attended with any arterial 
murmur. 

Anemia and chlorosis, on the other hand, are very uniformly 
characterized by an arterial blowing sound, which may be either 
intermittent or continuous. In these diseases, the density of the 
blood, and in many cases its quantity, are diminished, and the ner- 
vous excitability of the patient is so much augmented, that the 
heart contracts more frequently and actively than in health. 
These conditions, it must be admitted, comprise all that are essen- 
tial to the production of sound by a fluid moving through a tube 
with a certain velocity. The causes of the intermittent bellows' 
murmur have been sufficiently discussed. The continuous mur- 
mur, so called, is, in fact, composed of two separate sounds. The 
one is synchronous with the first sound of the heart, and the other 
fills up the whole interval between the repetitions of the former, 
and having much the same tone, forms with it a prolonged and 
undulating murmur, which sometimes resembles the blowing of a 
blacksmith's bellows, sometimes the sound of a humming-top, 
{bruit de (liable), the cooing of a dove, the whistling of the wind, 



soft bellows' murmurs. 355 

&c. Its first part, which is the loudest and most prolonged, is 
due to the passage of thinned and impoverished blood through the 
arteries, and is synchronous with the pulse. The second part is 
ascribed by some writers to the contraction of the artery upon 
this altered blood, but by others, and with better reason, it is 
asserted to take place in the veins, particularly in the internal and 
external jugulars. Or, more correctly, it is said that in anemic 
cases, where this murmur exists, it is constant in the veins, but 
being masked at every moment by the louder sound which takes 
place in the arteries, the resulting impression upon the ear is of 
two distinct sounds running into one another. 

The following experiment, proposed by M. Aran, proves the 
correctness of the above explanation. The stethoscope being 
placed over the carotid artery, just above the internal extremity of 
the clavicle, and in the triangular depression which there exists, 
the murmur is distinctly heard ; if, then, the circulation in the ex- 
ternal jugular vein be arrested by pressure with the end of the fin- 
ger, at a point above the stethoscope, the murmur at once becomes 
intermittent ; or if this do not succeed entirely, in consequence of 
the continuous sound being formed in the internal jugular vein, 
the result is certainly obtained by pressing at the same time slightly 
with the forefinger, at a point on the edge of the sterno-mastoid 
muscle, just above the middle of the neck. The continuous mur- 
mur immediately ceases, while the arterial sound remains un- 
altered. 

The intensity of these sounds is always directly proportioned to 
the impoverishment of the blood. It has been amply demonstrated 
by MM. Andral and Gavarret, that they not only depend upon a 
decrease of the proportion of the red globules of the blood, but that, 
taking a series of chlorotic cases, these murmurs are almost uni- 
formly heard whenever the proportion of globules does not exceed 
80, but that between this and the normal proportion, 127, the bel- 
lows' murmur is more frequently intermittent. 

The soft blowing murmurs, whether continuous or intermittent, 
deserve to be regarded as of the highest importance in determining 
the diagnosis of anemic cases, and particularly as a means of dis- 
tinguishing the palpitations, syncope, dyspncea, dec., which are apt 



356 SEMEIOLOGY. 






to attend them, from analogous symptoms due to organic disease 
of the heart. MM. Behier and Hardy relate a case in point. A 
lad fourteen years of age, and of a sanguine temperament, pre- 
sented nearly every symptom of organic disease of the heart, dysp- 
noea, violent palpitations, precordial impulse, and a bellows' mur- 
mur in the first sound. A diagnosis of hypertrophy was already 
made out, when a continuous humming over the right carotid 
artery revealed the error. Similar mistakes are of very frequent 
occurrence in this country, and patients are subjected to sedative 
medicines, repose, and depletion, for disorders which a little more 
accurate knowledge would have led the physician to cure with 
tonics, exercise, and nutritious food. 

Cerebral auscultatory signs. — As the vascular murmurs are the 
most numerous of those discoverable by cerebral auscultation, this 
appears to be the proper occasion for a brief notice of their 
character and semeiologial value. Dr. J. D. Fisher, of Boston, 
is entitled to the credit of discovering that, in certain morbid states 
of the contents of the cranium, peculiar sounds are generated. He 
first announced the fact in 1833, and five years afterwards pub- 
lished several cases confirmatory of his original statements. In 
1843, Dr. Whitney, of Newton, Mass., published an account of 
his observations in the same field, corroborating the views of his 
predecessor, and furnishing some novel results. 

It appears, from the essays of these gentlemen, that on ausculting 
the head of a healthy person, and particularly the region of the 
anterior fontanelle in a young child, the sounds of the heart, of 
respiration, of the voice, and of deglutition, are more or less audible. 
But, whenever the blood within the cranium is increased in quantity, 
its movement accelerated, or it is thrown into unusual vibration by 
the roughness of its channel, or its own tenuity, all the physical 
conditions exist which are requisite for the production of abnormal 
murmurs. 

Of the morbid cephalic sounds, the most common is the bellows' 
murmur, which, it is stated, may be heard in simple and ephemeral 
congestion of the brain, such as exists directly after a paroxysm of 
whooping-cough; in "acute cerebral inflammation ; hydrocephalus ; 
compression of the brain ; scirrhous induration of the substance of 



CEPHALIC MURMURS. 357 

the brain with softening; ossification of the arteries of the brain, 
and the hydrencephaioid disease." This murmur is described as 
being synchronous with the pulse ; as sometimes continuous and 
sometimes interrupted, and as either abrupt and blowing, coarse 
and rasping, soft and diffusive, or somewhat musical. The last- 
mentioned character is noticed only when there is well-marked 
anemia. In a case of aneurism of the basilar artery, related by 
Dr. Whitney, the murmur was harsh and rough, accompanied with 
a diffused and purring vibratory thrill, and became much softer 
when pressure was made upon the carotids. 

The physician just named has described a murmur called ce- 
phalic segophony, which he believes to be pathognomonic of serous 
effusion within or upon the brain, as thoracic segophony is of effu- 
sion into the pleural cavity. " It resembles very much," he says, 
"the shrill brazen sound produced by speaking through the teeth 
of a comb covered with paper or thin cloth." Supposing this sign 
to have the value which is attached to it by its discoverer, it cer- 
tainly possesses some importance in practice, as a differential sign 
between the hydrencephaioid symptoms of anemia, and true hy- 
drocephalus, conditions which are often confounded by the best 
practitioners. 

The purring murmur may be useful in distinguishing aneurismal 
from other tumours within the cranium. But, as regards the bel- 
lows' sounds, it is not easy to perceive to what extent they facilitate 
the diagnosis of cerebral affections, since they exist equally in sim- 
ple congestion, and in various inflammatory and structural diseases 
of the encephalon. A sign which is equally characteristic of the 
state of cerebral excitement which occurs during dentition, and of 
positive meningitis, abscess of the brain, and hydrocephalus, can- 
not, certainly, be of great importance. If we rightly appreciate 
auscultatory signs in thoracic and cardiac affections, they are valu- 
able as indicating the seat, nature, and extent of the existing dis- 
ease ; but, with the exceptions already pointed out, it does not ap- 
pear that the cephalic murmurs reveal either the part of the brain 
which is affected, or the particular change which it has undergone. 
A cephalic blowing murmur seems to stand in a relation to cerebral 
diseases, very much like that of a cough to pulmonary disorders ; 



358 SEMEIOLOGY. 

as a symptom which may depend upon any one of a great variety 
of dissimilar causes, and therefore inviting investigation in regard 
to them, although in itself of little semeiological importance. But 
even in this view, the murmurs in question are of secondary con- 
sequence, because they do not appear to have existed in any case 
in which attention was not already drawn to the brain by other 
cerebral symptoms. 

The writers on cerebral auscultation do not mention having lis- 
tened for the bellows' murmur in cases of fever, whether essential 
or symptomatic of inflammation seated elsewhere than in the brain. 
If the phenomena, described by them, occur from moderate con- 
cussion, or from momentary congestion after coughing, they, in all 
probability, would be present whenever the brain is sympathetically 
affected. 

Signs from the veins. — Amongst the symptoms belonging to the 
venous system, is pulsation of the jugular veins, an occurrence 
already adverted to, and which is due to some obstacle to the pas- 
sage of the blood through the right side of the heart, and causing 
a reflux into the descending vena cava. This obstacle may consist 
in narrowing of the tricuspid orifice, in which case the reflux is 
occasioned only by the systole of the auricle ; in a patulous state 
of this orifice, or in stricture of the pulmonary artery, causing the 
blood to regurgitate, during the ventricular systole; or, finally, in 
congestion of the lungs, such as takes place in asphyxia, when the 
blood accumulates in the right cavities of the heart, and the con- 
traction of the auricle tends to force its contents into the vena cava 
rather than into the ventricle. 

An abnormal communication between a vein and an artery, or 
aneurismal varix, is accompanied with pulsatory novements in the 
vein, in consequence of the blood being driven into it during the 
arterial diastole; but this pulsation does not extend beyond two or 
three inches from the abnormal opening. These are the only cir- 
cumstances in which a true venous pulse exists. This name is in- 
correctly given to the rising and falling of a vein which happens 
to lie over a superficial artery. Sometimes, in consequence of the 
juxtaposition noticed, when phlebotomy is performed in the median- 
basilic vein, the jet of blood, instead of being perfectly continuous, 



VENOUS PULSATION, DISTENTION, ETC. 359 

may have an intermittent or jerking movement, which is very apt 
to alarm the inexperienced practitioner with the apprehension that 
he has wounded the subjacent artery. The dark colour of the 
blood is sufficient evidence that the artery is unhurt. 

The subcutaneous or superficial veins are usually distended under 
the influence of heat, and in plethora ; and contracted by cold, and 
in anemia. But the local alterations in the size of these vessels 
are more directly connected with the present subject. They may 
be enlarged when an unusual amount of blood is thrown into a part, 
as in active congestion, or when an obstacle arrests the return of 
the blood through one or more venous trunks. The former case 
is illustrated by that turgidness of the veins of the neck and head 
which sometimes precedes apoplexy, and that of the back of the 
foot when gout attacks the joint of the great toe. Fulness of the 
veins of the face and neck is very common in diseases of the lungs 
impeding the circulation through these organs, provided the amount 
of blood in the body be not much reduced ; in severe cases the 
entire venous system becomes turgid, forming an acute variety of 
cyanosis. In the ordinary congenital form of this latter disease, 
the same result ensues from contraction of the pulmonary artery, 
or some analogous lesion, preventing a free circulation through the 
right side of the heart. 

Distension of the superficial veins of the abdomen is frequently 
due to some impediment to the portal circulation, particularly to 
that form of hepatic atrophy called cirrhosis, and which is one of 
the most ordinary causes of ascites, when this affection is inde- 
pendent of general dropsy. Distension of the veins of the lower 
extremities may arise, either from pressure upon the venous trunks 
within the pelvis, by the gravid uterus, a pelvic tumour, collections 
of fasces in the rectum or colon, or to the habit of standing when 
fatigued. This distension may become permanent through the 
prolonged action of any of the mechanical causes mentioned, and 
the walls of the vessels become thickened and indurated. 

Signs from the circulation in the gravid uterus, and the festal 
heart. — In connexion with the preceding account of the semeiology 
of the circulatory apparatus, it seems proper to notice briefly the 
sounds which are detected in the uterus during pregnancy. These 



360 SEMEIOLOGY. 

are chiefly two : 1st, the uterine bellows' murmur, and 2d, the sounds 
of the fetal heart. 

The uterine bellows' murmur is heard by applying the ear, either 
directly, or through the medium of a stethoscope, to the walls of 
the abdomen, where they come, or can be brought into contact, 
with the uterus. Its tone resembles closely that produced by com- 
pressing with the stethoscope a large artery, but differs from this 
in being unaccompanied with pulsation or heaving. It is sometimes 
very abrupt, and sometimes so prolonged as to be almost continu- 
ous. Generally it is distinctly audible, and does not seem to be 
distant from the ear ; but occasionally it is so feeble as to be heard 
with great difficulty. Its tone varies considerably, not only in the 
same individual, but even during an examination, being sometimes 
sonorous, sometimes acute, or whistling, &c. The following pro- 
positions, which are taken from the recent work of M. Depaul,* 
present a summary of all that need be said of this murmur. 

1st. This murmur is generated in the uterine arteries, and not 
in the placenta, and may be heard at all points of the organ acces- 
sible to the ear or the stethoscope. 

2d. It is proved by incontestable facts, that the uterine murmur 
has been heard at the middle of the eleventh, and even at the close 
of the tenth week. But, in general, it cannot be detected until 
somewhat later. 

3d. It grows progressively louder until the end of the seventh 
month ; after which it usually remains unaltered. 

4th. It is incorrectly regarded by many physicians as a certain 
sign of pregnancy. Of itself, it has not a much higher value than 
the rational signs ; but combined with several others, it gives to 
them, as well as acquires, importance. 

5th. It cannot be doubted that a murmur perfectly analogous to 
the one under consideration may exist when the uterus is distended 
under any other circumstances than pregnancy. 

6th. The death of the fcetus in nowise alters this sound, still less 
arrests it. Its absence, therefore, is no proof of the child's death. 

* Traite Theorique et Pratique d' Auscultation Obstetricale, par J. A. H. 
Depaul. Paris, 1847. 



UTERINE AND FCETAL SOUNDS. 361 

7th. It is equally uninfluenced by the diseases which may affect 
the fetus. 

8th. Admitting that the size of the placenta bears some propor. 
tion to that of the child, the size of the child cannot be predicated 
upon the loudness of the uterine murmur, inasmuch as this sound 
is independent of the placenta. On this account, also, the tone, 
&c, of the murmur, afford no indication of placentary disease, 
nor can the situation where the former is heard determine at 
what point the placenta is attached. 

9th. It is an error deduced from a false theory, to assert that 
double pregnancies may be inferred from the existence of 'several 
uterine murmurs. Anatomy teaches that even when there are two 
foetuses there is usually but one placenta, and experience shows 
that there may be two, and even three, distinct murmurs, although 
the womb contain but a single foetus. 

10th. It results from the foregoing summary that the practical 
value of the uterine murmur, as a sign, is very restricted indeed. 

The sounds of the fcetal heart. — These sounds resemble very 
much the ticking of a watch, except that they have not its metallic 
tone. They are two in number, are very close together, and yet 
perfectly separate. The first is louder and longer than the second, 
which occasionally grows very faint or quite inaudible. The 
number of these pairs of sounds, so to speak, varies from 120 to 
150 per minute, and, according to some writers, remains the same 
throughout pregnancy, but according to others, becomes less 
during the last few weeks. In general, they grow more distinct 
as gestation advances, but various causes may modify their dis- 
tinctness. Such, for example, are a profusion of liquor amnii, 
unusual thickness of the abdominal walls, great mobility of the 
womb, and that position of the fcetus in which its back is towards 
the spine of the mother. During uterine contractions, also, there 
is a muscular sound which masks that of the foetal heart. Disorder 
of the mother's circulation has no direct influence on that of the child. 

The following conclusions are chiefly borrowed from the work 
of M. Depaul, already quoted. It is generally stated, that the 
foetal pulsations are not audible before the middle of the fifth 
month, but they may very commonly be heard at three months 



362 SEMEIOLOGY. 

and a half, and even earlier. M. Depaul claims to have distin- 
guished them at the end of the third month, and of the eleventh 
week. 

During the last three months of pregnancy, these sounds are 
almost always present, unless the foetus has perished. They are 
not wanting once in a hundred times. 

The region of the uterus where they may be heard, depends 
chiefly upon the position of the foetus ; its left scapula is believed 
by M. Depaul to correspond, in the immense majority of cases, to 
the point at which the sounds in question are loudest. 

The presence of these sounds of course establishes, not only 
the fact of pregnancy, but that of the foetus being alive, and has, 
therefore, this great advantage as a sign, that it may be detected 
while other symptoms are indistinct and lead only to a doubtful 
conclusion. On the other hand, the absence of the sounds is more 
to be depended upon as a sign of the death of the foetus than any 
other symptoms whatever. 

Two sets of pulsations, heard at different points, and not pre- 
cisely simultaneous, should be regarded as an unquestionable sign 
of double pregnancy. 

According to M. Depaul, it is possible, in the vast majority of 
cases of advanced pregnancy, to ascertain the position of the foetus 
in utero. Indeed, if the sounds of the foetal heart are most dis- 
tinctly heard at points of the uterus to which the left scapular re- 
gion of the foetus is nearest, and this region is nearer the cephalic 
than the pelvic extremity of the child, it follows that when the 
foetal sounds are heard loudest below the middle horizontal line of 
the uterus, there will be a presentation of the head ; when heard 
above such line, there will be a presentation of the pelvic end of 
the fcetal ellipse ; when heard to the right or to the left of the mid- 
dle vertical line of the uterus, a first or third position of one or the 
other extremity, may be presumed to exist. 

But, to confirm the correctness of these results, it is necessary 
that auscultation be practised carefully, and no point assumed to 
correspond to the foetal heart unless it be well ascertained that the 
maximum loudness of the foetal sounds exists there. It is also 
necessary that the examination be renewed from time to time, for 



SOUNDS OF THE F(ETAL HEART. 363 

it is certain that the position and presentation of the foetus may 
both change spontaneously. 

That these minuter details of diagnosis are not attended to by a 
larger number of obstetric practitioners, is probably owing to their 
not having the experience or the skill in the art of auscultation 
which a methodical application of them demands. Those who 
have enjoyed the best opportunities for testing the method, ascribe 
to it the highest value. 



CHAPTER VI. 

SIGNS FROM THE RESPIRATORY APPARATUS. 

The morbid phenomena presented by the organs of respiration 
are very numerous, but by far the greater number of them are 
direct indications of thoracic disease ; very few, indeed, arise 
from sympathy with the disorder of other systems. For the 
purpose of study, they may be conveniently divided into those 
which are detected by the ordinary methods of observation, and 
those revealed by physical examination alone. The former 
class includes the various alterations of the act of breathing, 
dyspnoea, expectoration, cough, and several forms of pain; the 
latter comprises the modifications of the resonance of the chest, of 
the respiratory sounds, and of the voice, with the several rhonchi 
or rattles which may be discovered by auscultation. 



SECTION I. 

THE SO-CALLED RATIONAL SIGNS OF PULMONARY DISEASE; INCLUD- 
ING RESPIRATION, DYSPN03A, COUGH, THE SPUTA, ETC. 

Respiration consists of two parts, inspiration and expiration. 
By the healthy adult, this act is performed from 12 to 20 times in 
a minute, by the infant from 20 to 30 times in the same space, 
during a state of perfect repose. Respiration is rendered much 
more frequent by exercise, by emotion, by the process of diges- 
tion, &c. ; but the action of these causes is very brief, and, 
when it has ceased, the breathing resumes its previous moderation. 
Inspiration occupies about thrice the time of expiration ; some 
writers, however, regard the two acts as equal, and others assert 
that the former bears to the latter the proportion of 5 to 1. Up- 



THE RESPIRATION IN DISEASE. 365 

questionably, all these proportions are quite compatible with health, 
and may be noticed in the same individual, in the course of a few 
minutes' observation ; but the one first mentioned will be found to 
express most accurately the average standard. 

In disease, the respiration may be preternaturally frequent or 
slow, rising to 60 or 80, or falling to 8 or 10, in a minute. The 
former condition is common to all febrile and inflammatory affec- 
tions of a sthenic type, especially when they attack children. As 
a general rule, however, extremely rapid breathing is a sign of 
thoracic disease ; but even then it is proportioned to the grade of 
fever present, unless when associated with dyspnoea, in which 
case its degree more directly depends upon the amount of pulmo- 
nary tissue withdrawn from the purposes of respiration, by disease. 
When, from any cause, the inspirations are short and very fre- 
quent, and particularly when this effect is produced by extensive* 
effusion into the pleural cavities, the breathing resembles that of a 
person who is " out of breath" with running, and is called panting 
respiration. As mental emotion quickens the respiration tempo- 
rarily, so do certain nervous diseases increase its frequency more 
permanently. It is not uncommon for hysterical females to breathe 
60 or 70 times a minute, during an entire paroxysm of the disease. 
Slow respiration is seldom, if ever, an attendant upon pulmonary 
disease, but nearly always of some affection, either structural or 
functional, of the nervous system. It is observed in apoplexy, 
effusions of serum within the cranium, and softening of the brain, 
and in most of the circumstances which occasion coma. In nearly 
all of these cases, not only is the respiratory act very slowly per- 
formed, but the intervals between the inspirations are unusually 
long. A similar condition is met with in catalepsy, extasis, me- 
lancholy monomania, and in persons under the influence of de- 
pressing passions. 

Inspiration, it was stated, is naturally longer than expiration. 
Sometimes this proportion is exaggerated, and sometimes reversed. 
For example, in oedema of the glottis, the swollen edges of this 
opening are drawn downwards, so as to obstruct, and therefore 
prolong the passage of the air into the larynx, but they offer no 
impediment to its escape, so that the expiratory act is short and 

31* 



366 SEMEIOLOGY. 

easy. On the other hand, when the lungs are emphysematous, 
the air enters them readily, but in consequence of their rigidity, 
they contract slowly, and therefore a prolonged expiration is pro- 
duced. 

Normal inspiration is uniform and continuous ; but when the 
pleura is inflamed, or the muscles of the chest are affected with 
rheumatism, the pain caused by drawing the breath arrests the ex- 
pansive movement at every instant, and renders the inspiration 
jerking and irregular. 

Many varieties of morbid respiration, besides the above, are de- 
scribed by authors, but the following are the most important: 

Abdominal respiration, in which the diaphragm chiefly exerts 
itself, causing the abdomen to rise and fall considerably, while the 
walls of the chest are nearly at rest. This usually occurs in acute 
•pleurisy, rheumatism of the chest, pericarditis, and fracture of the 
ribs; in all of which affections, movements of the chest excite 
pain. 

Thoracic, or high respiration, when the abdomen does not move, 
but respiration is performed entirely by expansion of the chest. 
This is found, in a marked decree, when the peritonaeum, the di- 
aphragm, or its pleural covering, is inflamed. Distention of the 
abdomen, by wind or water, or by tumours, will have the same 
effect. 

Cervical respiration, and cephalic respiration, are terms denoting 
the part taken by the muscles of the neck, and those which dilate 
the nostrils during the struggles for breath, which mark the severer 
forms of dyspnoea. 

In health, respiration is performed noiselessly; but not always 
so in disease. It is wheezing, in simple laryngitis and in croup, 
and generally has a clear whistling tone in stridulous laryngitis, 
and nervous asthma. It is suspirious, or sighing, when the inspi- 
ration is short and quick, and the expiration prolonged, as happens 
during recovery from syncope, in low forms of fever, and often on 
the approach of death from asphyxia. It is plaintive or moaning, 
either from extreme debility or from pain. When it arises from the 
latter cause, it is not a sign of peculiar gravity ; but when it occurs 
during sleep, unless excited by an unpleasant dream, it is a most 



DYSPNtEA. 367 

unfavourable indication. Stertorous^or snoring respiration, is one 
of the frequent attendants of coma, and adds to the gravity of this 
symptom, whenever the latter depends upon congestion, or any 
other mode of pressure upon the brain. It may depend merely 
upon the habit of the patient, or upon a polypous tumour in the 
nostrils, cases which are of course to be distinguished from those 
where it forms an incident of the principal disease. Cold respira- 
tion, in which the expired air is below the ordinary temperature of 
the body, is nearly always a mortal symptom ; yet it has occasion- 
ally been met with in the cold stage of intermittents, and in the col- 
lapse of cholera, without being followed by death. 

Dyspnaza. — Under this title is included every form of laborious 
or difficult respiration, accompanied with a sense of constriction or 
oppression arq,pnd the base or on the front of the chest. In its 
slightest degree, there is some panting, and an unwonted effort to 
expand the chest, but only after some unusual exertion. When 
more marked, the ribs are raised by a still stronger effort, and the 
diaphragm is greatly depressed; yet the air does not seem to reach 
the pulmonary vesicles. The voice is faltering or gasping, and 
the patient cannot lie in bed unless the head is propped up high 
with pillows. 

The causes of dyspnoea, although very numerous, may, perhaps, 
be all resolved into one general and essential cause: an obstacle to 
the due aeration of the blood. A healthy person, exhausted by ex- 
ercise or running, has dyspnoea, because the natural supply of air, 
afforded by the lungs, is insufficient to modify the blood which 
rushes, in a greatly augmented quantity, into those organs. The 
increased action of the chest, the hard breathing, is nature's 
method of maintaining the balance between the functions of the 
heart and lungs. But, whether the circulation be increased in 
activity, or the lungs so altered as to admit but little blood to 
come in contact with the air, or the heart or great vessels so 
changed as to impede the passage of the blood towards the lungs, 
or the respiratory muscles so feeble as to be unable to dilate the 
chest, one and the same result ensues : enough blood is not aerated 
to supply the wants of the economy, and a more or less vigorous 
and successful effort is made, by means of the voluntary muscles, 



368 SEMEIOLOGY. 

to expand the chest, and relieve the sense of suffocation which in- 
cites to this effort. Consequently, whether the disease be an effu- 
sion of blood or serum into the pericardium, compressing the heart, 
or such a state of that organ as causes it to propel an undue quan- 
tity of blood into the lungs, or such disease of its valves as either 
prevents the blood from reaching the lungs, or from passing freely 
through them ; — whether the lungs themselves be hepatized or in- 
filtrated with tubercles, or have their cells thickened by emphysema, 
or choked up by mucus or blood, as in bronchitis and pulmonary 
hemorrhage, or compressed by gas, pus, or serum, as in pneumo- 
thorax, empyema, and pleurisy; or whether, finally, the respira- 
tory muscles be debilitated by cerebral or any other disease — the 
consequences are still of the same kind : the blood fails to undergo 
the changes for the accomplishment of which the pulmonary circu- 
lation exists, impending suffocation gives warning of the mischief, 
and a laborious attempt is made to overcome the incompleteness 
and inadequacy of the inspiration, generally by rendering them 
more frequent. 

Such are extreme cases. But, when any of the causes enumera- 
ted act with less energy, an involuntary increase in the frequency 
of the respiration will usually take place, sufficient to overcome 
the difficulty at least for a season. The patient is scarcely con- 
scious of breathing, more actively than usual, unless when he ex- 
erts himself beyond his strength ; he feels no oppression, no short- 
ness of breath. But as the disease which occasions the dyspnoea 
advances, the involuntary acts of respiration are no longer suffi- 
cient to introduce into the lungs the necessary amount of air, and 
the patient's attention being aroused by a sense of oppression, he 
endeavours to make up for the deficiency by assuming such posi- 
tions as favour the action of the respiratory muscles. He leans 
forward and grasps his knees, or some article of furniture, so as to 
make his head and shoulders fixed points, and bring into play the 
pectorales, and other muscles which pass from the chest to the 
humerus. The degree of oppressed breathing, in which no relief 
is found, except in the partially erect posture, is called orthopn&a, 
(from ogdoC, straight ; and ttvsw, I respire.) 

Dyspnoea is more or less severe, according to the nature of the 



DYSPNOEA. 369 

disease, and especially the extent of the lesion. Pneumonia may 
invade one, or even all the lobes of a lung, without producing any 
notable shortness of breath, or increased frequency of the respira- 
tion. In acute pleurisy, the dyspnoea is more considerable, but 
chiefly because the act of breathing is painful ; for in chronic pleu- 
risy there is no pain, and often but little oppression. In double 
pneumonia or pleurisy, on the other hand, when hardly any of the 
pulmonary tissue is left in a condition to perform its function, the 
oppression is extreme. Phthisis, also, induces very little dyspnoea, 
except what arises from debility, until tuberculization of the lungs 
has taken place to a great extent. Diseases of the heart, and em- 
physema, when general, create very distressing shortness of breath, 
(orthopnea,) because they influence the function of the whole pul- 
monary tissue. 

In most of the affections of the lungs and heart, attended with 
dyspnoea, this symptom is of gradual growth, and its increase 
shows the progress of the original disease. This is its course in 
inflammations of the lungs and pleurae, of the fauces and the air- 
passages, in pulmonary phthisis and dropsy of the pericardium and 
chest, in acute as well as structural diseases of the heart and great 
vessels, and in anemia and chlorosis. Sometimes, on the contrary, 
the invasion of this symptom is sudden and justly alarming ; for, if 
accompanied with sinking or collapse, it nearly always indicates a 
rupture of the heart or aorta, or perforation of the pleura by a 
pulmonary vomica. 

In nearly all acute inflammatory affections, and in phthisis, ane- 
mia and chlorosis, dyspnoea has seldom a paroxysmal character, 
although it may be aggravated by exercise, emotion, &c. But in 
most of the organic diseases of the heart, and in emphysema, with 
which they are so often connected, paroxysms may occur at regu- 
lar intervals, particularly at night, or rather, early in the morning. 
In the suffocative diseases of the larynx, also, there are paroxysms 
of dyspnoea, even in those which run their course in a few hours or 
days: as pseudo-membranous laryngitis (croup), stridulous laryn- 
gitis, and oedema of the glottis. There are two diseases, (nervous 
asthma and angina pectoris,) of which almost the only essential 
phenomena are, paroxysms of dyspnoea; for although, in the for- 



370 SEMEIOLOGY. 

mer malady, there is the most intense suffering for want of breath, 
and in the latter, the most excruciating pain extending from the 
breast to either arm, yet in the intervals between the attacks, the 
patients may enjoy excellent health. 

Yawning is a deep and prolonged inspiration with the mouth 
wide open, and followed by a short and strong expiration ; often it 
is accompanied with a slow but complete stretching of the limbs, 
especially the upper limbs, which is called 'pandiculation. The 
whole act is involuntary. It is an ordinary precursor of acute 
attacks of febrile disease, and is then generally attended with chil- 
liness ; it also is apt to precede paroxysms of nervous disorder. 
Gaping, in diseases of a typhoid type, is a sign of great prostra- 
tion, and one, therefore, of unfavourable import. 

Hiccup or singultus, already noticed under another head, is a 
momentary convulsion of the diaphragm, accompanied with a con- 
striction of the glottis, which prevents the entrance of air into the 
lungs. It is often a slight and temporary disorder, caused, usually, 
by the pressure of undigested food in the stomach, or the over-dis- 
tension of this organ with flatus. It becomes, however, a sign of 
importance, and is most unpropitious, when it occurs in low fevers, 
after surgical operations, and in inflammations of the abdominal 
viscera. In the first of these cases it may last for several days, 
and by its perpetual annoyance, and its rendering sleep impossible, 
augment very considerably the danger of the patient. After sur- 
gical operations it is indicative of the failure of the patient's 
strength, and sometimes of the occurrence of metastatic abscesses. 
In strangulated hernia, intestinal obstructions, and visceral inflam- 
mations, if hiccup supervene along with feebleness and increased 
frequency of the pulse, gangrene is to be apprehended. 

Cough. — Coughing consists in the rapid and noisy passage 
through the glottis of air driven out of the lungs by a short, quick, 
and forcible expiration, and resounding in the nasal fossae. It may 
be either voluntary or instinctive. It is commonly excited by a 
tickling in the larynx or trachea, or by a sense of fulness or 
oppression in the chest. 

The tone of the cough varies considerably, and often affords 
valuable information to the experienced ear. Some of the more 



YAWNING — HICCUP COUGHING. 371 

striking varieties in regard to tone are, the hoarse cough of com- 
mencing catarrh, the hollow cough of advanced consumption, the 
sharp ringing or crowing cough of stridulous laryngitis, the smo- 
thered cough of croup, the whooping cough of pertussis, and so on. 
In the last-mentioned disorder the cough is paroxysmal ; in nearly 
all others it comes on irregularly, and is excited by the presence 
of secretions in the air-passages, exertion of the voice, exposure to 
cold air, &c. 

Coughing is, for the most part, symptomatic of some affection 
of the respiratory apparatus, but occasionally, also, of disease in 
other organs, the liver, the heart, or the stomach, for example. 
In the latter case it is commonly dry, that is, unaccompanied with 
sputa. It must be borne in mind, however, that what is some- 
times called a "stomach cough," and is observed in the dyspeptic, 
is in reality a sign of commencing tuberculization of the lungs. 
A very common origin of dry cough, and one which is frequently 
overlooked, is elongation of the uvula. This organ, in the cases 
alluded to, irritates the opening of the larynx, and produces a con- 
stant and very distressing cough. In opposition to the dry cough 
is that called loose, in reference to the copiousness of the secretion 
into the air-passages, and the facility of its removal. The latter 
is usually unaccompanied with pain, and is followed by a sense of 
relief, while the dry cough, or that in which the sputa are scanty, 
produces soreness, or even smarting or burning throughout the 
lungs, or in the trachea and larynx only, if these parts are prin- 
cipally involved. Violent coughing also causes pain in one or 
both sides, or at the point of the sternum, or around the whole 
line of attachment of the diaphragm, making these parts feel as if 
they had been bruised. 

Of itself, cough does not afford sufficient ground for a sure diag- 
nosis, but is chiefly valuable in this relation when considered along 
with other symptoms. To this rule there is, perhaps, one exception. 
In pertussis, the cough is not only paroxysmal, and attended with 
extreme congestion of the blood-vessels of the face, but it consists 
of several successive and quick expirations, followed by a long, 
sonorous, and "whooping" inspiration, unlike what takes place 
in any other disease whatever. 



372 SEMEIOLOGY. 

The croupal cough, so called, in which there is a shrill, ringing 
sound during expiration, is far from being characteristic of true 
croup; it is, in fact, far more common in spasmodic or stridulous 
laryngitis, and when it does accompany the pseudo-membranous 
affection, it is only at the commencement of the attack; when 
once false membranes are exuded, the cough becomes dull and 
smothered. 

Cough excited by laryngeal disease ma} T generally be recognised 
by its being often a voluntary act, performed for the purpose of 
expelling a body that seems to be sticking in the throat, and chiefly 
through the action of the muscles of the throat, while that which 
depends upon pulmonary or bronchial disease is louder, more in- 
stinctive, and effected mainly by the muscles of the chest and the 
diaphragm. Inflammatory affections of any part of the air-pas- 
sages or lungs excite very frequent coughing, while in pleurisy, 
whether acute or chronic, the cough is infrequent, and in the for- 
mer variety, short and irregular. Besides the cases mentioned 
above, the cough is dry in the commencing stage of nearly all pul- 
monary affections, and becomes humid at the height, and loose, 
especially during the decline of these maladies. 

In 2^>'ognosis this symptom has not a definite value, aside from 
its aiding in the discrimination of the disease; but as it may exist 
almost alone, in one affection at least, it becomes important, by 
drawing attention to the state of the patient. In phthisis, it is very 
frequently the first, and for a long time the only distinct symptom, 
and should lead to inquiries concerning the hereditary predisposi- 
tion of the patient, as to whether he has lost flesh, has had hemop- 
tisis or pains in the chest, and it particularly calls for an examina- 
tion of his lungs by percussion and auscultation. The suspension 
or cessation of cough in the latter stages of pulmonary affections 
attended with copious expectoration is an evil sign, for it shows the 
patient to be in immediate danger of suffocation from the secretions 
which then accumulate in the bronchial tubes. 

Expectoration — Expuition, or spitting, is the act of discharging 
saliva, or other matters, from the mouth ; hawking consists in 
forcing them from the throat into the mouth; and expectoration, in 
expelling the solid or liquid contents of the air-passages. Sputa 



EXPECTORATION. 373 

are the substances rejected by these acts combined. The term ex- 
pectoration is commonly used to include both of the other acts. It 
is quite as frequently, but much more erroneously, employed as 
synonymous with sputa, as in the phrases, purulent, mucous, and 
bloody " expectoration," instead of expectoration of pus, mucus, 
and blood. 

The present subject may be conveniently studied under two 
heads ; first, the act of expectoration ; and second, the matters ex- 
pectorated, or sputa. Expectoration is nearly always produced by 
coughing, although, as has been shown, there may be cough with- 
out sputa. A sensation, capable of exciting cough, is produced at 
some point in the air-passages, the opening of the glottis contracts, 
and the air in the lungs is forced along the bronchial tubes, carry- 
ing with it the mucus or whatever else obstructs its passage, which 
it throws into the posterior fauces and mouth. On other occasions, 
as when profuse pulmonary hemorrhage occurs, or an abscess or 
aneurism breaks into the air tubes, a portion of the fluid is rejected 
by the simple compression of the lungs during expiration ; when 
no more can escape in this manner, coughing comes on, and expels 
the remainder. This explanation of the mechanism of expectora- 
tion affords a reason for the difficulty with which the act is per- 
formed under certain circumstances. Thus, in capillary bronchi- 
tis, oedema of the lungs, and other affections where the offending 
substance occupies the ultimate ramifications of the bronchia, the 
cough is hard, and continues for some time before the successive 
compressions of the lungs succeed in forcing forward the mucus, 
&c, to a point where the air can act upon and propel them to- 
wards the fauces. The same explanation applies equally to cases 
in which the secretion into the bronchia is very scanty, and to 
those where it is profuse ; for in the one the substance to be re- 
moved does not present a sufficient surface to the current of air in 
which it is placed, as in the first stage of nearly all pulmonary 
affections; and in the other the mass to be removed is out of pro- 
portion to the volume of air which acts upon it. This latter diffi- 
culty is greatly enhanced when the patient is already weak, and 
cannot, either instinctively or by an effort of the will, contract the 
expiratory muscles of the chest with sufficient energy. The want 

32 



374 SEMEIOLOGY. 

of this power is a frequent cause of death in old persons, in debili- 
tating fevers, in apoplexy, &c. ; although, at the same time, the 
power of living seems far from extinct in the rest of the organism, 
the lungs fill up with mucus, the cough grows feebler, and at last 
ceases, and the tracheal rattle announces that but a few moments 
more of life remain. The difficulty of expectoration may be ex- 
plained in like manner, when the secretions are so tenacious as to 
adhere firmly to the bronchia, and resist the action of the air. 
Such is the case in suffocative catarrh, in the first stages of simple 
bronchitis, in pneumonia also, and when, as in the chronic bron- 
chitis which complicates emphysema, the secretion is at once viscid 
and profuse. 

The Sputa. — In thoracic diseases, the matters expectorated are 
various in quantity, form, colour, consistence, smell, and composi- 
tion, and offer numerous points of interest to the student of semeio- 
logy. 

The sputa are scanty, as before remarked, in the forming stage 
of nearly all pulmonary complaints ; yet occasionally, some of 
these complaints may run their course, even to a fatal termination, 
without expectoration. This has been noticed in phthisis and in 
pneumonia ; in the latter disease, occurring as a complication of 
typhoid fever, the exhaustion of the patient sometimes deprives 
him of the power to expectorate. In other cases, again, of primi- 
tive pneumonia, the sputa have been entirely wanting. 

Setting aside the cases noticed in which the air tubes have merely 
served as channels for the escape of the contents of an abscess, 
&c., the sputa are much more copious in chronic than in acute 
pulmonary disorders, and most of all in those affecting the bron- 
chia themselves. In the disease called bronchorrhea, quarts of a 
watery fluid may be voided in the course of a day ; and in chronic 
bronchitis, with dilatation of the bronchia, an almost equal quantity 
of muco-purulent matter. Occasionally, when there is a large 
tuberculous cavity in a lung, it alternately fills and empties itself, j 
sometimes discharging suddenly a stream of pus. It should be 
borne in mind, that many persons past the meridian of life, expec 
torate most profusely, without their health in any manner suffering 



THE SPUTA. 375 

from this apparent waste ; on the contrary, they are never so well 
as when the discharge is plentiful and free. 

The form of sputa depends a good deal upon their consistence. 
When very firm, they are apt to exhibit ragged edges in the spit- 
toon, and when viscid and gelatinous, as they usually are in pneu- 
monia, they form in the vessel a homogeneous semitransparent 
mass, resembling the white of egg, which is often so tenacious as 
to retain its hold, even when the vessel is inverted. Frothy sputa, 
formed by the thorough admixture of mucus and air, and floating 
on a somewhat viscid liquid, belong to the febrile stage of bron- 
chitis, to emphysema, and pulmonary oedema. Nummular sputa, 
so called from their fancied resemblance to a piece of money 
(nummus), are opaque, regularly rounded, with sharp edges, and 
do not run together. They are most frequently met with in pul- 
monary consumption, but are not exclusively characteristic of that 
disease ; they are quite as uniformly produced by the bronchitis 
which accompanies measles, and sometimes occur in cases of 
simple chronic bronchitis. A form of sputa, which is indeed rare, 
but, when it exists, of much greater value as a sign of pulmonary 
tubercles, consists in little yellowish or whitish masses, bearing a 
strong resemblance to grains of boiled rice, and which swim in a 
turbid and watery mucus. These bodies are, in reality, tubercles, 
and must be carefully distinguished from others which closely re- 
semble them, yellowish, cheesy masses, extremely foetid when 
crushed, and which consist of the accumulated and putrid secre- 
tion of the crypts in the tonsils and about the root of the tongue. 
Small, compact, and very white sputa are seldom observed, except 
in chronic inflammation of the larynx. Sputa vary greatly in 
their consistence. The thinnest of all are the serous, which are 
met with in most cases of commencing catarrh, in pulmonary em- 
physema, and in congestion of the lungs produced by disease of 
the heart. Ordinary mucous sputa, such as accompany acute 
bronchitis, are somewhat more tenacious, and during the decline 
of this affection, much more so ; they acquire their greatest degree 
of tenacity in the second stage of pneumonia and capillary bron- 
chitis. Unmixed purulent, sputa are rarely met with, except from 
the discharge of an abscess into the air tubes: in some cases of 



376 SEMEIOLOGY. 

chronic bronchitis, and of large cavities in the lungs, they are 
nearly pure, and in all these affections, they approach more or less 
to the creamy consistence of pus derived from ordinary sources. 

The odour of the sputa expectorated in acute bronchitis and 
commencing phthisis, is, generally, faint or sweetish, and during 
the decline of the former complaint, they acquire a sickening 
smell. In chronic catarrh, particularly when pus is expectorated, 
in advanced consumption, and in ulcerative laryngitis, they are 
usually somewhat foetid. They have a decidedly alliaceous odour 
when a fistulous opening allows the contents of the pleura to 
escape through the lung, and an intolerably putrid smell in gan- 
grene of the lung. This horribly offensive character has some- 
times been observed in bronchitis, with dilatation of the air-tubes 
and purulent sputa. 

The colour of the sputa is not without value as an element of 
diagnosis. At the commencement of most thoracic diseases, they 
are whitish, and assume peculiar characters at a later stage. 
Thus, in bronchitis, as it tends towards resolution, they generally 
become greenish, and at the same time more homogeneous and 
opaque. During the height of pneumonia they grow tenacious, 
semi-transparent, and of a rusty colour, caused by the admixture 
of altered blood ; but, at a more advanced stage, they lose their 
viscidity, and resemble, in colour and consistence, tobacco juice. 
In phthisis they are whitish, and marked upon the surface by 
threads of a more opaque substance, which have been compared 
to filaments of vermicelli. Dark-coloured sputa are observed, 
also, in gangrene of the lung ; their dependence upon this cause 
is inferred from the accompanying foetor, and the prostration of 
the patient's strength. 

The composition of sputa offers numerous varieties, arising 
chiefly from the intermixture, in various proportions, of mucus, 
pus, serum, and blood. The circumstances under which the first 
three of these substances are rejected, have been summarily 
pointed out. Expectoration of pure blood, or of blood mixed with 
the pulmonary secretions, is by no means an unfailing sign of 
consumption. Blood may be discharged from the lungs under 
various circumstances. It may be a simple exhalation from the 



COMPOSITION OF THE SPUTA. 377 

bronchial mucous membrane, in consequence of the suppression 
of a sanguineous discharge, as of the menses, hemorrhoids, epis- 
taxis, &c., or from plethora alone, as in the adolescent of both 
sexes; it may take place during the early stages of phthisis, be- 
fore there is any destruction of tissue, or from the rupture of a 
vessel left bare by the evacuation of a tuberculous cavity, but the 
latter mode is extremely rare; it may depend upon pulmonary 
apoplexy, laryngeal hemorrhage, or the congestion of the lungs, 
produced by valvular disease of the heart; it may arise from the 
opening of an aneurism into the aif-passages, in which case it is 
usually much more profuse than in the vast majority of phthisical 
cases. Hemorrhage from the stomach, nose, fauces, and mouth, 
has been confounded with hsemoptysis, from which, however, it 
may be readily distinguished by a careful inquiry into the particu- 
lars of the individual case. 

Besides the fluids just mentioned, other substances are occasion- 
ally expectorated. Such are the plugs and shreds of fibrin which 
are discharged in some cases of suffocating catarrh, and in croup. 
Their rejection, it is evident, is favourable to the recovery of the 
patient. In rare instances, small masses of calcareous matter are 
expectorated, which, it is probable, consist of transformed tuber- 
culous matter. In the course of laryngeal phthisis, which is nearly 
always either tuberculous or syphilitic, portions of necrosed bone 
are sometimes discharged, which are fragments either of the os 
hyoides, or of the ossified cartilages of the larynx. The sputa 
have sometimes an urinous smell, which may proceed from sup- 
pression of the renal function, or, more rarely, from the actual 
presence of urine in the pulmonary discharge. The following 
case illustrates the latter statement. In 1840, there was a sailor 
in the Pennsylvania Hospital who had long suffered from stricture 
of the urethra. He was attacked with inflammation of the bladder; 
the acute symptoms of the complaint were relieved, but the urine 
continued to present a muco-purulcnt sediment. Subsequently, 
pain began to be felt in the left lumbar region, where, also, a tumour 
developed itself. Then pleurisy of the left side came on, with ex- 
treme dyspnoea. About this time a profuse discharge of pus hav- 
ing an urinous smell took place from the mouth; hectic fever then 

32* 



378 SEMEIOLOGY. 

sat in, and the patient gradually sank. On examination of his 
body after death, there was found to be a continuous passage from 
the bladder to the mouth, by means of the ureter, kidney, a fistu- 
lous communication between a large renal abscess and the lung, 
and finally the bronchia and trachea. Another patient in the same 
institution had received a gun-shot wound in the right hypochon- 
drium. In course of time, there was a sudden and copious expec- 
toration of pus, followed by that of a small quantity of bile, and 
the latter substance continued for many days to appear in the 
sputa. This patient entirely recovered. 

The mode in which the sputa are discharged, taken in con- 
nexion with their qualities, assists in determining their source. 
When they are formed in the mouth, they are mucous, transpa- 
rent, and abundant, and are generally due to inflammation of the 
mucous membrane, or of the follicles, of this cavity. They are 
fcetid in mercurial salivation and in necrosis of the palatine bones, 
and both offensive and tinged with blood in scurvy and gangrene 
of the mouth. They may either stream from the lips without any 
effort on the part of the patient, or be rejected by the mere act of 
spitting. When the sputa proceed from the posterior fauces, their 
expulsion is effected by the act of hawking, accompanied sometimes 
with snuffling, by which the contents of the nostrils are drawn into 
the throat. Sputa from this source are generally composed of 
ropy mucus, as in acute inflammation of the tonsils or pharynx; 
or of pure, but stinking pus, as when an abscess of the tonsil 
opens, or of streaks of pus, as in the ulcerative form of chronic pha- 
ryngitis ; or of fcetid and sometimes bloody pus, as in ozasna ; or 
of false membranes, as in pseudo-membranous pharyngitis. 

Sputa from laryngeal affections are generally small, mucous, 
purulent, or streaked with blood, according to the nature of the 
disease. They are expelled by coughing, but by a short, quick 
cough, which speedily removes the offending substance, and is ac- 
companied with a feeling of soreness or burning in the larynx. 
The voice is generally rendered less husky and hoarse by each 
act of laryngeal expectoration. Cough from laryngeal disease, 
when there are no sputa to expel, is usually severe and constant. 
Sputa which proceed from the lungs themselves, are nearly always 



SOURCES OF THE SPUTA THORACIC PAIN. 379 

more abundant and individually larger than those last mentioned, 
and they are accompanied with more energetic coughing, in which 
the whole thorax takes part. 

One variety of pain in the thorax has already been described 
as a soreness around the base of the chest, due to violent cough- 
ing ; and another, the stitch in the side, experienced in acute 
pleurisy. This pleuritic pain is felt in nearly all cases of pneu- 
monia, because, in fact, the pleura is inflamed as well as the tissue 
proper of the lung. Its usual seat is about the region of the nipple. 
In phthisis, there is usually a lancinating pain in the chest, felt 
more frequently between the shoulders and below the clavicle, than 
elsewhere. It has been ascribed to the circumscribed pleurisy 
which is so generally excited by the presence of tubercles in the 
upper lobe of the lung, the ordinary seat of these bodies. In some 
cases of this disease the pain is decidedly neuralgic. 



SECTION II. 

PHYSICAL SIGNS IN DISEASES OF THE RESPIRATORY APPARATUS. 

In a previous chapter, the methods employed for detecting, during 
life, the various physical alterations to which the organs are sub- 
ject, have been sufficiently detailed ; the signs derived from inspec- 
tion of the chest have also been pointed out in their appropriate 
place. There only remains now to be considered the application 
of percussion and auscultation to diseases of the lungs ; a subject 
which, from the accuracy and value of the practical information 
it includes, deserves the most thorough investigation by every medi- 
cal man, and will be presented in the following pages with as much 
completeness as the prescribed limits of the work will allow. 

Of percussion in diseases of the lungs. — It has before been stated, 
that mere resonance or dulness of any part of the chest, is of no 
positive value in diagnosis, but only the degree of either as com- 
pared with the natural resonance of that part. Thus, in the region 
lying along the spinal column, the ribs have but little elasticity, 
and are covered by thick muscles; while in that bordering on the 



380 SEMEIOLOGY. 

sternum, there is scarcely any muscular development, and the elas- 
ticity of the ribs is very great. Here, then, are two points, of which 
one is naturally dull, and the other naturally resonant on percus- 
sion. In like manner, every other part of the chest has a degree 
of resonance, which it is necessary to be acquainted with in order 
to draw correct inferences from the results of percussion in dis- 
ease. 

Here it may be mentioned, that the cavity occupied by the lungs 
is not wholly bounded by the ribs, but that the summit of the lungs 
rises behind the inner end of the clavicles, to the distance of an inch 
or even more; a fact of much importance relatively to the first 
physical signs of pulmonary tubercles, but one not sufficiently re- 
garded. The inner portions of both lungs converge, and usually 
come into contact (two thin layers of pleura only intervening), just 
behind the junction of the first and second bones of the sternum, 
and' lie side by side as low as the junction of the fourth costal 
cartilages with the sternum. The sternal margin of the right lung 
continues almost vertically downwards to about the anterior end of 
the sixth rib, where it is joined nearly at a right angle by the in- 
ferior margin. The inner margin of the left lung passes obliquely 
outwards from the fourth rib around the precordial region, and de- 
scends about an inch lower than the lung of the opposite side. The 
inferior posterior bounds of both lungs are just behind the junc- 
tions of the twelfth ribs with the vertebrce, and pass directly out- 
wards and forwards.* 

Within these limits there are many degrees of resonance or per- 
cussion, according to the thickness of the thoracic parietes, and of 
the tissue of the lurjg beneath the point percussed. The following 
summary, of which the principal points are derived from MM. 
Barth and Roger's Treatise, will be found a sufficient guide in prac- 
tice : — 

Anterior regions. — Above the clavicle, particularly above its 
sternal extremity, upon this bone, and between it and the fourth 
rib, the sound on percussion is clear; but in the mammary region, 
particularly in fat persons, it loses something of its clearness. On 

* Mr. Sibson ; op. cit. 



PERCUSSION OF THE CHEST NORMAL SOUNDS. 381 

the left side, the sound becomes dull in the precordial region, be- 
low which it regains the proper pulmonary resonance, until the 
seventh rib is reached, where the tympanitic sound of the stomach 
takes its place. On the right side, the sound is clear from the neck 
to the sixth or seventh rib, where it becomes considerably duller, 
and the resistance increases, from the presence of the liver. The 
upper third of the sternum gives a clear sound on percussion ; the 
lower two-thirds are dull. 

Lateral regions.— The axillary portions are very resonant, and 
the parts below them somewhat less so, as the liver is approached 
upon the right, and the spleen upon the left side, except when the 
stomach is distended with gas. In that case, the sound is more in- 
tense than the pulmonary, and becomes tympanitic. 

Posterior regions. — Directly above the spine of the scapula, per- 
cussion yields a dull sound ; and below this limit, one that is some- 
what less dull. Below the scapula, again, the sound is generally 
clear: and most so along the line formed by the angles of the ribs, 
until the limits of the liver and spleen are reached upon the two sides 
respectively. The dulness on the right side begins a little higher 
up than on the left, in consequence of the bulk of the liver. In 
the space on either side of the spinal Column, the sound is tole- 
rably clear, but gradually diminishes towards the lower part of the 
chest. 

Besides these regional varieties in the clearness of the sound, 
there are others, depending upon the age of the patient and the 
condition of the thorax. In old persons of spare habit, it is very 
marked ; in young children, still more so; and, as a general rule, 
the more capacious the chest, and the thinner its walls, the louder 
is the sound elicited by percussion. During complete expiration, 
the sound is decidedly duller than when the chest is fully distended 
with air. 

Percussion of the chest, in disease, shows lhat the sound is either 
louder or duller than natural, or has acquired an unnatural tone. 
Increased loudness may be either general or local. The former, as 
a morbid change, is rarely observed upon both sides of the chest ; 
never, perhaps, except in general pulmonary emphysema, and in 
emphysema of the walls of the chest. But even then there is a differ- 



382 SEMEIOLOGY. 

ence in the resistance of the two sides. Loud resonance is usually 
confined to one side, and its most striking degree is owing to 
the distention of the pleural cavity with air, in consequence of a 
tuberculous perforation of the lung. Yet, in this case, the tympa- 
nitic or drum-like resonance, does not often occupy the whole side 
of the chest ; because, in phthisical subjects, a portion only of the 
pleural cavity is left free when adhesions have taken place between 
the pulmonary and costal pleurce. In pulmonary emphysema, the 
whole of one lung may be more resonant than the other, but not 
equally so in every part ; it nearly always affords a clearer sound 
about the junction of the ribs with their cartilages, than else- 
where, but at no point so loud a sound as that obtained in pneumo- 
thorax. 

Local increase in loudness of sound is observed in pulmonary 
emphysema, and usually at the points indicated in the last para- 
graph. The extent of the resonance corresponds to that of the di- 
latation of the air-cells which constitutes the disease. When large 
cavities are formed in the lung, and near its surface, (conditions 
which seldom exist except in the superior lobes,) percussion of the 
chest above them produces a loud and clear sound which is almost 
tympanitic. A similar sound has occasionally been noticed in the 
same region when a serous effusion occupied the pleural cavity be- 
low this level. 

Diminished sound on percussion, is a much more ordinary 
symptom of the thoracic disease than augmented resonance, and, 
like it, may be either general or partial, that is, may extend to the 
whole of one side of the chest, or to a part only of one or both 
sides. Avenbrugger, the inventor of percussion, pointed out the 
value of this sign so clearly that little remained for his successors 
but to illustrate the general proposition laid down by him. "If," 
says he, " at a point of the thorax which is naturally resonant when 
struck with a certain force, equally forcible percussion elicit an 
obscure sound, there is disease at that point ; and if the sound pro- 
duced be absolutely dull, like that from striking a muscular part, 
the disease occupies the whole extent of this dull space, [f, then, 
• the patient is directed to take a full inspiration, and on percussion 



PERCUSSION OF THE CHEST MORBID SOUNDS. 383 

being made while he holds his breath, the dulness is found to con- 
tinue, the disease extends deeply into the chest." 

Diminution of clearness is often met with in percussion of the 
thorax, although there may be no morbid condition present, but 
only increased thickness of the parietes from adipose or muscular 
development. This case is easily recognised by the sounds being 
equally obscure upon both sides. Serous or purulent infiltration, 
and cancerous degeneration of the walls of the chest, may diminish 
its resonance in the parts where these affections exist, and the sus- 
pension of the respiratory movements of one side in consequence 
of muscular rheumatism, or other local painful disorder, by causing 
the corresponding lung to receive less air than the opposite one, 
diminishes to some extent its resonance on percussion. 

Dulness on percussion is the ordinary sign of pleuritic effusions. 
If the amount of fluid is considerable, the absence of sonorous 
sound is complete, and the finger used as a pleximeter perceives 
that the natural elasticity of the chest no longer exists. This dul- 
ness is first perceived at the lowest point of the thoracic cavity, 
(which is at its side,) and, as the effusion increases, the dulness 
extends upwards. The superior boundary of this zone is not, as 
might be supposed, a horizontal line, but one curving upwards, and 
the highest point of which is in the line of the axilla. The dulness 
is always greatest towards the base of the chest when the effusion 
is only partial, but in some instances it occupies the whole space 
where, naturally, the pulmonary sound exists, showing that the 
entire cavity of the pleura is filled with fluid. Generally, in acute 
pleurisy, and always in hydrothorax, the level of the liquid, and 
consequently the line of dulness, is changed whenever the posture 
of the patient is altered ; in both of these diseases, also, when the 
effusion is very considerable, the organs bordering upon the lungs 
may be thrust from their places. The heart in effusions of the left 
pleura may, as before mentioned, be thrust to the opposite side of 
the sternum, and in those of the right side, the liver may encroach 
considerably upon the cavity of the abdomen. 

Dulness depending upon augmented density of the pulmonary 
tissue undergoes no change, whatever the posture of the patient 
may be ; it is not so perfect as that resulting from an effused 



384 SEMEIOLOOY. 

liquid, nor, in general, so accurately limited, but, usually in more 
than one direction from the point where it is most distinct, it gra- 
dually diminishes until lost in the normal pulmonary sound. It 
very seldom exists over the whole of one side of the chest. He- 
patization of the lung and tuberculous deposits are its ordinary 
causes. When due to the former, it corresponds, in a large majo- 
rity of cases, to the posterior part of one lung, whence it may ex- 
tend laterally and anteriorly. In a small proportion of instances 
it commences in, and is confined to, the superior lobe. In hypo- 
static pneumonia, or that which accompanies low fevers, and is due 
to the patient's lying constantly in the supine position, the dulness 
occupies both sides of the chest behind, from its base half-way, or 
further, towards its summit. In tuberculization, on the other hand, 
the dulness is generally first perceived in the neighbourhood of the 
clavicles, or above the spine of the scapula, and often upon both 
sides at once. 

It was stated above, that increased resonance is sometimes met 
with when a large cavity exists at the summit of the lung, and the 
walls of the chest are thin. Under these circumstances, also, two 
sounds having special characters, or rather two varieties of the 
same sound, are yielded by percussion. The one is simply a 
somewhat metallic tone, which is attributed to the presence of 
liquid as well as air in the cavity ; the other resembles the sound 
produced by striking a cracked porcelain or metallic vessel, and 
" is most closely imitated by the sound resulting from striking the 
back of the hands, loosely folded across each other, against the 
knee, the contained air being forced out quickly and abundantly 
between the fingers at each blow." To produce this sound by 
percussion, the cavity must be superficial, have flexible walls, and 
contain both air and liquid. It is, however, a sign of little value, 
and can often be elicited in thin, but healthy persons, by striking 
upon the clavicle while the mouth is open. 

It must be apparent, from the preceding remarks, that percussion 
reveals but one symptom, furnishes but one element of diagnosis. 
Although that symptom is often of paramount importance, yet it is 
but a single one, and rarely, if ever, is of itself sufficient for deter- 
mining the nature of the disease. The knowledge derived from 



THE NORMAL RESPIRATORY MURMURS. 385 

percussion is limited to one of the three following cases: either the 
particular region of the chest examined preserves its natural sono- 
rousness, proving that the parts beneath it retain their proper den- 
sity ; or it is more resonant than natural, and the subjacent parts 
have undergone a change diminishing their density ; or it yields a 
dull sound, showing that a denser substance than natural receives 
the impulse of percussion. If the resonance is increased, it still 
remains to be inquired whether the air which produces it is con- 
tained in the lungs, as in emphysema, or in the pleural cavity, as 
in pneumothorax. If dulness exists, other means must be em- 
ployed in order to discover whether it depends upon effusion into 
the subcutaneous cellular tissue; on false membranes, or on 
serous or purulent effusion into the cavity of the pleura ; or on 
pneumonia, pulmonary congestion, or infiltration of the lung with 
serum, or with tuberculous, or cancerous matter. Percussion, in 
this case, merely shows when a comparatively dense body occupies 
the place which in health is occupied by a substance of inferior 
density. Auscultation, and the general symptoms, must determine 
what that body is, and how it affects the general system. The 
nature of the disease being thus ascertained, the extent of the 
structural alteration, as determined by percussion, comes in to form 
an element in the prognosis of the case. 

Of auscultation in diseases, of the lungs. — When the ear is ap- 
plied directly, or through the medium of a stethoscope, to the chest 
of a healthy individual, there is heard, during inspiration, a soft and 
mellow murmur, which is called vesicular, because supposed to be 
produced by the entrance of air into the pulmonary vesicles. This 
sound is most distinct where the walls of the chest are thinnest, 
and the vesicular structure predominates, as in the axilla and the 
lower part of the chest, both in front and behind. At these points, 
no sound is audible during expiration, but a slight murmur may be 
perceived in the neighbourhood of the larger bronchia, at the root 
of the lungs, above the spine of the scapula, (especially on the 
right side,) and in some cases, immediately below the clavicle of 
the same side, as was first pointed out by Dr. Gerhard. Both the 
inspiratory and expiratory sounds are louder in children than in 
adults, and, in the former, have a peculiar shrillness of tone, which 

33 



386 SEMEIOLOGY. 

has received the name of 'puerile respiration. The character of 
the inspiratory murmur varies in different parts of the chest ; as 
already stated, it is mellow in the parenchymatous structure, over 
the larger bronchia it js less prolonged and gentle, and over the 
trachea and larynx it is decidedly blowing. This blowing laryn- 
geal sound is so loud as to be propagated to a certain distance 
along the air-passages, but is not, as some have maintained, the 
origin of the murmur called vesicular. 

Many considerations might be adduced to demonstrate this pro- 
position ; but let one suffice. A case which the writer had the 
good fortune to witness, in Paris, in 1837, and which was reported 
by M. Barth, seems decisive in regard to the cause of the vesicular 
murmur. A man had disease of the larynx, and was in imminent 
danger of suffocation. His trachea was opened, and a canula in- 
troduced through the wound, enabling him to breathe freely. Be- 
fore the operation, the laryngeal sounds were so loud that they 
could be heard at some distance from the patient, while no respi- 
ratory murmur could be detected in any part of the chest what- 
ever. As soon as the patient began to breathe through the canula, 
the vesicular murmur became perfectly audible throughout the 
chest, and had precisely the same tone as in health, although the 
sounds heard in the trachea, and generated by the passage of air 
through the silver tube, were quite different from those naturally 
produced in the larynx. This case appears to render it certain, 
that the vesicular murmur is independent of the sounds formed in 
the larynx and trachea, and that the essential condition for its pro- 
duction is the free entrance of air into the lungs. It must, how- 
ever, be borne in mind, that when a portion of the lung becomes 
solidified by disease, it acquires an increased power of conducting 
sound, and may transmit to the ear tracheal and bronchial mur- 
murs at points where, in health, they are wholly inaudible. 

We shall have occasion frequently to refer to the facility with 
which sounds, generated in the interior of the lung, are transmitted 
to the surface of the chest, when the intervening substance is denser 
than natural. It is true that this phenomenon is, in a great mea- 
sure, due to the superior power possessed by dense bodies of con- 
ducting sound ; but it is also, in part, owing to the circumstance 



CAUSES OF THE NORMAL MURMURS. '387 

that the bronchial tubes enter into vibration more readily when they 
are surrounded by an uniform and comparatively dense substance, 
than when the vesicular structure remains normal ; that is to say, 
when it is composed of two substances, air and flaccid pulmonary 
tissue, which are not consonant in their vibrations, and are, beside 
subdivided as to break up and destroy the original vibration occur- 
ring in the bronchia. A compressed, or solidified lung, therefore, 
gives the parietes of the bronchial tubes an increased power of 
vibrating in consonance with the air contained within them, 
whether this latter be thrown into agitation by the act of inspira- 
tion, or by the voice, or other sounds generated in the larynx. 
Two causes, then, may be assigned for the augmented resonance 
of intra-thoracic sounds in the cases alluded to ; first, that more 
sound is actually generated in the bronchia; and, secondly, a bet- 
ter conducting medium than natural conveys it to the ear of the 
auscultator. 

In the further discussion of pulmonary auscultation, will be con- 
sidered ; 1st, the modifications of the natural respiratory sounds 
in loudness, rhythm, and quality ; 2d, The sounds which may be 
combined with these or supersede them, called rhonchi ; and 3d, 
The sounds termed by Dr. Walshe " adventitious," including the 
voice, cough, &c. 

Modifications of the natural respiratory murmurs. — These 
murmurs may be abnormally strong, or feeble, or altogether sup- 
pressed. Strong, loud, or puerile respiration appears to be due to 
the entrance of air in more than usual quantity, or with unusual 
force, into the pulmonary cells; for whatever increases the action 
of the whole, or any part of the lungs, gives to the vesicular mur- 
mur more or less of the puerile character. When unwonted acti- 
vity of the respiration is owing to excitement of the nervous, or 
circulatory system, the puerile sound is audible over the whole of 
both sides of the chest ; when heard throughout one side only, it 
usually depends upon a serous effusion in the opposite pleura corn- 
pressing the lung ; or upon serous, bloody, fibrinous, or tubercular 
infiltration in that lung, or some other cause capable of preventing 
the free access of air into its vesicles, and consequently imposing 
additional labour upon the sound one. In like manner, such com- 



388* SEMEIOLOGY. 

pression or infiltration of a portion of one lung induces puerile 
respiration in its remaining parts. Hence, exaggeration of the re- 
spiratory murmur at one point, indicates that another portion of the 
lung has been deprived of its function, and suggests a further in- 
quiry as to the seat and nature of the thus indicated lesion. 

Feeble respiration is a symptom of frequent occurrence, and of 
great importance in thoracic disease. It may be due, either to ori- 
ginal faintness of the respiratory murmur, or to the difficulty this 
sound has in traversing the walls of the chest. The first of these 
cases exists either when the expansion of the chest is imperfect, when 
disease of the larynx impedes the admission of air into the lungs, 
or when a portion of the cellular structure is occupied by a solid 
or liquid. In the two former instances the feebleness is general, 
and in the last it is local. The respiratory murmur is prevented 
from reaching the ear when the thickness of the external integu- 
ments is very great, and also when a serous effusion, or other ac- 
cidental production within the chest, intervenes between the lungs 
and the ear. In the case of serous effusion, however, the vesicular 
murmur is actually fainter than natural, because the lung is under 
compression, unless indeed, the effusion is very moderate ; in which 
case it. is, of course, confined to the lowest part of the chest. False 
membranes lining the pleura have a similar effect. The respira- 
tion is extremely feeble in vesicular emphysema, probably because 
the walls of the cells are too rigid to collapse and expand with the 
movements of the thorax, and therefore not in a condition to gene- 
rate sonorous currents of air, as the healthy vesicles must do. One 
of the earliest signs of tuberculous deposits in the lung is local 
feebleness of respiration ; for these foreign bodies fill up some of 
the cells, and compress the adjacent ones. Cancerous growths of 
the lung itself produce the same effect, and when such tumours in 
the mediastinum, or aneurisms of the great vessels, compress the 
trachea or the larger bronchia, the respiratory sounds are more or 
less diminished, according to the position of the tumour and the 
degree of pressure it exerts. Pressure upon the lungs from below, 
as in enlargements of the liver and abdominal dropsy, diminishes 
the vesicular murmur. 

[n all of these cases, while the vesicular murmur may be extreme- 



LOUD AND FEEBLE RESTIRATION. 389 

ly faint, other sounds are heard in its stead, and particularly that of 
bronchial respiration. But, it sometimes happens, that when the ear 
is applied to the chest, nothing whatever is heard; all the respira- 
tory sounds are suppressed. The conditions requisite to produce 
this result are of the same nature as those just enumerated; but 
they are of a higher degree, and, instead of merely enfeebling the 
vesicular and bronchial murmurs, suppress both of them com- 
pletely. 

The diagnosis of thoracic disease can be aided greatly by con- 
sidering the circumstances under which feeble respiration occurs. 
When detected about the base of the thorax, and apparently re- 
mote from the ear, while dulness on percussion exists at the same 
point, it indicates pleuritic effusion. Heard over the whole of one 
side of the chest, with natural resonance on percussion, and a stitch 
in the side, but without fever or cough, it generally depends upon 
rheumatism of the thoracic muscles. Existing upon one side, along 
with elevation of the ribs, and a tympanitic sound on percussion, it 
is a sign of pneumothorax. When it prevails over the entire thorax, 
with dyspnoea, while the resonance on percussion remains natural, 
there is an obstacle to the passage of the air through the larynx or 
trachea. If it is partial and temporary, accompanied with mucous 
rhonchus, and superseded by the natural respiratory sound after 
coughing, it is due to bronchitis. When it exists over a considerable 
space, on one or both sides of the chest, and especially about the an- 
terior extremities of the true ribs — when, too, it is accompanied with 
sibilant rhonchus, projection of the intercostal spaces, and augment- 
ed resonance on percussion — it is unquestionably produced by em- 
physema of the lungs. At the summit of one or both lungs, feeble- 
ness of respiration, with diminished resonance on percussion, is a 
strong evidence of the existence of crude tubercles at these points. 

The rhythm of the respiratory sounds may be affected by 
changes in their frequency, regularity, and duration, both absolute 
and relative. The last of these points is the only one to be con- 
sidered here, the others having already been discussed. Of the 
alterations in the relative length of inspiration and expiration, the 
only important one is prolonged expiration. In a perfectly healthy 
condition of the lung, little or no sound accompanies the expiratory 

33* 



390 SEMEIOLOGY. 

act, except over the larger bronchial tubes ; but in proportion as 
the lung is rendered more dense by disease, the expiratory murmur 
becomes gradually more and more distinct, so as to mask the mur- 
mur of inspiration, which indeed grows feebler as the other be- 
comes developed. The existence and the semeiological value of this 
important symptom, were first established by the late Dr. Jackson, 
of Boston, who proved that when, from any cause, the pulmonary 
tissue acquires a greater density than natural, prolonged expiration 
is audible before the blowing sound of bronchial inspiration can be 
perceived. However this may be explained, and no satisfactory 
explanation has yet been proposed, the fact is now universally ad- 
mitted. Its most valuable application is in cases of commencing 
phthisis. Although it is true that, at the summit of the right lung, 
a slight expiratory murmur may be heard in the majority of cases, 
yet if this be prolonged, and loud enough to mask the sound of in- 
spiration, there is reason to apprehend that tubercles are developed 
at that point, and the suspicion acquires augmented gravity, if there 
is also diminished resonance at the sternal end of the clavicle. 
These signs are much more certainly indicative of pulmonary con- 
sumption, if they are found at the summit of the left lung, because, 
at this point, there is scarcely ever the least expiratory sound in 
health. 

The quality of the respiratory sounds may be altered. They 
are still, indeed, heard, but their tone is different, for they 
are no longer generated in the vesicular structure exclusively 
if at all, but chiefly or altogether in the bronchial tubes, or in a 
cavity resulting from disease. These alterations have received 
the names of harsh, bronchial, cavernous, and amphoric respira- 
tion. 

"In harsh respiration," says Dr. Walshe, " both murmurs have 
lost their natural softness ; a peculiar dryness accompanies them ; 
the breezy character of health is exchanged for one sharper and 
more blowing, which is generally more marked in expiration than 
inspiration." It is a lower grade of bronchial respiration, and the 
anatomical conditions essential to producing it, are the same in 
kind, but not in degree. When mucus in the finer bronchia, or tu- 
bercles in the parenchyma, or any similar cause, partially cuts off 



EXPIRATION BRONCHIAL RESPIRATION. 391 

the entrance of air into the vesicles, the natural respiratory mur- 
mur is not wholly suppressed, but is mingled with the rougher 
bronchial sound, which reaches the ear all the more readily that the 
lung has become denser* Harsh respiration is heard over the greater 
part of the chest, accompanied with more or less sibilant rhon- 
chus, during the early stages of bronchitis ; over the posterior and 
lower part of the chest, and attended with fever, in the commencing 
stage of pneumonia ; along the free margin of the lungs, with in- 
creased resonance of this region on percussion, in vesicular emphy- 
sema ; under one or both clavicles, with prolonged expiration, reso- 
nance of the voice, and dulness on percussion, in the forming stage 
of pulmonary consumption. 

Bronchial respiration, which, with the two following varieties, 
may be comprised under the general head of blowing respiration, 
is so called because it takes place in the bronchial tubes alone, the 
parenchyma of the part where it is heard being quite inaccessible 
to air. A very correct idea of this sound may be obtained by 
breathing to and fro through the half-closed hand. It is heard both 
in expiration and inspiration, and is generally loudest in the former, 
in which, also, it is earliest manifested. Bronchial respiration may 
be heard at any part of the chest, but is commonly most distinct 
at the root of the lungs, and wherever the air-tubes are largest and 
most superficial. It varies greatly in tone, being sometimes merely 
harsh, and in other cases almost of a metallic character. This dif- 
ference depends chiefly upon the greater and more uniform density 
of the parts intervening between the ear and the bronchia where 
the sound is generated. 

Bronchial respiration is met with in numerous diseases of the 
chest, especially pneumonia, phthisis, pulmonary apoplexy and 
oedema, pleuritic effusions, dilatation of the bronchia, and, occasion- 
ally, in cancer of the lung. It is most strongly marked in lobar 
pneumonia, during the stage of hepatization ; and its degree, and 
the space in which it is audible, depend on the completeness and 
extent of the solidification. Hence, in lobular pneumonia, this sign 
is often wanting. It is also an ordinary symptom of pleuritic effu- 
sion, but not so constantly as of pneumonia ; for in the former dis- 
ease the lung is compressed, its bronchial tubes virtually obliterated 



392 SEMEIOLOGY. 

in great part, and its tissue is not so solid, and, consequently, not 
so good a conductor of sound as that of a hepatized lung. It is 
also prevented from coming in contact with the walls of the chest 
by the effusion, which thus, by adding to the number of media, im- 
pairs the transmissibility of the sound. Moreover, bronchial respi- 
ration may be very distinct at the commencement of a case of 
pleurisy, but grow fainter as the effusion increases, and at last 
cease to be heard altogether, if the effusion be very great. The 
character and coincident circumstances of bronchial respiration, in 
the two diseases, are different. In. pneumonia it is loud, sharp, and 
close to the ear, and is heard throughout the whole space which is 
dull on percussion. In pleurisy it is heard chiefly sit the root of 
the lung, while dulness exists over, perhaps, the lower half or two- 
thirds of the lung ; and if heard elsewhere, it is always feeblest 
where the dulness is most decided. Finally, the tone of the pleu- 
ritic blowing-sound, has a certain feebleness and meagreness, very 
different from the sonorous character of that belonging to pneu- 
monia. 

The modified respiration in question is frequently met with in 
the crude stage of pulmonary tubercles, or a little later, but seldom 
elsewhere than at the summit of the lung, where the tubercular de- 
posit is abundant enough to fulfil the conditions for its production. 
If this sound be heard at the summit of the lung, when there is no 
evidence of pneumonia, it affords ground for a just suspicion of 
tubercles; if the part be also dull on percussion, the presumption 
gains in strength ; and if, in addition, there be heard a humid cre- 
pitus, there is no longer room for doubt. 

Cavernous respiration is an exaggeration of the bronchial va- 
riety, which may be imitated by breathing forcibly into the hands 
half closed, and held over the nose and mouth. It is heard when 
a large and superficial cavity in the lung containing little or no 
liquid communicates freely with the large bronchial tube. Such 
cavities must, of course, in a vast majority of cases, be the result 
of the softening and discharge of tuberculous masses, and are 
therefore of most frequent occurrence in the upper lobes of the 
lungs. Hence bronchial respiration is generally heard near the 
clavicle, in the axilla, or above the spine of the scapula, and as it 



CAVERNOUS AND AMPHORIC RESPIRATION. 393 

cannot take place unless the cavity is nearly or quite empty, it is 
suspended whenever the secretion accumulates, and may therefore 
be heard one day and cease on the next, or be superseded by 
cavernous gurgling. This sound is also occasionally heard when 
portions of the pulmonary tissue have been destroyed by gangrene, 
or pneumonic abscess, or when a bronchial tube is so dilated as to 
form a globular cavity. Besides other characteristic signs of these 
affections, the fact that they are seldom seated near the summit of 
the lung suffices to distinguish them from tuberculous cavities ; 
and, on the other hand, when these latter are detected in the 
middle or lower part of the lungs, the upper portion nearly always 
presents the physical signs of tubercles, while the general symp- 
toms pretty clearly reveal the state of the patient. 

Amphoric is another form of blowing respiration, and is so 
called from its resemblance to the sound produced by blowing with 
moderate force into a narrow-necked bottle (amphora). It has a 
more metallic tone than cavernous respiration, and sometimes even 
acquires a marked silvery character, which, when once heard, is 
not easily forgotten. Whenever it exists, it supersedes the vesicular 
murmur entirely, and is generally audible during the whole period 
of inspiration. Like the last described sound, it frequently ceases 
to be heard for several hours or days together. Like that sound, 
too, it arises from the vibration of air in a large and empty cavity, 
and its loudness is proportioned to the size of the cavity and the 
force of the respiration. It exists, but in an imperfect manner, 
when there is a large tuberculous or other cavity in the lungs ; it 
is only heard in perfection when there is a perforation of the lung 
opening into the pleural cavity. In the former case there is more 
or less dulness on percussion over the comparatively restricted 
space within which amphoric respiration is audible ; in the latter, 
this sound pervades nearly the whole of one side of the chest, and 
is everywhere accompanied with tympanitic resonance on percus- 
sion. 

The Rhonchi. — This word, which, in the singular, means snort- 
ing or snoring, is used to designate certain morbid sounds in the 
lungs, some of which partake of this character. The French em- 
ploy the word rale, or rattle, for the same purpose. The rhonchi 



394 S EM EI O LOGY. 

are sounds which accompany, or rather take the place of, the nor- 
mal sounds of respiration, and are generated by the vibration of 
air in the bronchia or pulmonary vesicles, in consequence of the 
displacement of the liquids contained therein, or the partial ob- 
struction of their calibre. Various classifications of these sounds 
have been proposed. The following is probably, for the present 
purpose, sufficiently complete. 

Dry Rhonchi. \ 

I Sonorous. 

( Crepitant, 

Humid Rhonchi. < Sub-crepitant. 

( Gurgling. 

This general division, into dry and humid, is founded on the fact 
that the latter naturally suggest the idea of their being due to the 
movement of liquids, while the former want this character. 

The sibilant and sonorous rhonchi, although differing in cha- 
racter, are produced under circumstances so nearly identical, that 
they may very properly be regarded as varieties of the same 
sound. The former is the more acute of the two, and has a 
whistling tone, or resembles the chirping of a bird, the cooing of 
a dove, or the clicking sound of a valve. The latter is of a graver 
note, and often sounds like snoring. The two forms occur tooje- 
ther, or alternate with one another, and accompany either inspira- 
tion or expiration, or both. The sonorous variety, in particular, 
is sometimes loud enough to be heard at some distance, and in that 
case produces a vibratory tremour, which can be readily perceived 
upon applying the hand to the chest. The dry rhonchi are gene- 
rally audible over a considerable space, nearly always on both 
sides of the chest, and most distinctly upon its posterior surface. 
They are commonly ascribed to the swelling of the mucous mem- 
brane of the bronchia, or to the presence upon its surface of a cer- 
tain quantity of tenacious and adhesive mucus, which the passage 
of air through the bronchia throws into vibration. 

These rhonchi are most usually heard when the bronchial se- 
cretion is scanty, especially in the forming stage of acute bronchitis, 
and in that chronic variety of the disease to which the subjects of 
emphysema are so liable in wet and cold weather. In the latter 



DRY AND HUMID RHONCHI. 395 

disease the sonorous rhonchus is peculiarly distinct and loud, and 
has a marked wheezing character. 

The crepitant rhonchus is composed of a multitude of little, 
sharp, crackling sounds, precisely like those produced by gently 
rubbing a lock of hair between the thumb and finger, near the ear. 
It is audible during inspiration alone, and, when once established, 
remains unchanged by cough or expectoration, until superseded 
by some other rhonchus. At the lower and posterior part of the 
chest it is heard most frequently and distinctly, and rarely upon 
more than one side at the same time. The mechanism of this 
sound is not well understood, but of all the theories proposed for 
its explanation that of Dr. E. A. Carr, of Canandaigua, N. Y., and 
that of Dr. Walshe, of London, are the only ones which unite 
strong probabilities in their favour. According to both of these 
gentlemen the crepitation in question is produced by the forcible 
expansion of the pulmonary tissue, and the sudden separation of 
the glutinous particles with which it is filled. This act Dr. Walshe 
represents as taking place in the parenchyma around, and imme- 
diately contiguous to, the pulmonary vesicles; but as it is difficult 
to conceive how such a process could generate sound where no air 
exists, and as it is well known that the crepitant soon merges into 
the sub-crepitant rhonchus, which all admit takes place in the 
minute ramifications of the bronchia, we fully adopt the opinion of 
Dr. Carr, which is, that the crepitant rhonchus is formed in the 
vesicles themselves. The first effect of pneumonic inflammation, 
in which disease the crepitus in question is chiefly heard, is to in- 
spissate the mucus secreted in the radicles of the bronchia, and to 
fill the parenchyma with fibrin, thus augmenting the volume and 
density of the lung, and compressing the vesicles. The sides of 
these bodies being thus brought nearly into contact, every inspira- 
tion tends to separate them, and as the tenacious mucus which 
glues them together yields, the sound in question is produced. 

Crepitant rhonchus is the almost unfailing index of pneumonia 
in its forming stage, although it is occasionally observed in capil- 
lary bronchitis, and in oedema and congestion of the lung; but, in 
these affections, it lacks somewhat of the fineness and dryness 
which characterize it in the first mentioned disease. In pneumonia 



396 SEMEIOLOGY. 

it is followed by bronchial respiration, due to the hepatized state of 
the lung, and when resolution of this state commences, the crepitus 
once more becomes audible, but with altered characters. In fact 
it has then the qualities of the form next to be described, to wit : 

The sub-crepitant rhonchus. — This sound is also known as the 
mucous rhonchus, a faulty appellation, since it is produced by 
blood and pus, as well as by mucus. Like the crepitant, it con- 
sists of a succession of crackling sounds, which approach rather 
to bubbling, and its different degrees suggest the idea of its being 
formed by the explosion of smaller or larger bubbles. They have 
been aptly compared to the sounds made by blowing into soap-suds 
with tubes of different diameters. The sub-crepitant rhonchus is 
most abundant when the quantity of liquid in the bronchia is great- 
est, and loudest in proportion to the size of the tubes where it is 
generated, and the force of the respiration ; whence it is inferred 
to be produced by the passage of air to and fro through the liquids 
contained in the bronchial tubes. It is audible both in inspiration 
and expiration, is sometimes permanent, and sometimes temporarily 
suspended, particularly by cough and expectoration, and generally 
occupies the posterior and lower portion of both lungs. 

The sub-crepitant rhonchus is a sign of bronchitis, and succeeds 
the sonorous and sibilant rhonchi heard at the outset of this com- 
plaint. Beginning at the lower part of the lungs, it may gradually 
rise higher and higher, until it reaches the upper lobes, but it con- 
tinues to be most abundant near the base. Its "bubbles" are 
finest when the ultimate ramifications of the bronchia are involved, 
as in capillary bronchitis ; they have their most ordinary character 
in the tubes of medium size ; and in the largest, or when the bron- 
chia are dilated, and the liquid copious, the crepitus becomes so 
coarse as frequently to pass into gurgling. 

It has been stated that the sub-crepitant rhonchus is generally 
confined to the lower lobes of the lungs, or is, at least, most abun 
dant there. Sometimes, however, it is limited to the upper lobes 
but this never occurs in simple inflammatory bronchitis, — it is al 
ways an evidence that some local irritating cause exists, and tha 
cause is almost uniformly tubercles, tubercles in a state of soften 
ing, and forming numerous small cavities. The rhonchus in ques 



THE HUMID RHONCHI. 397 

tion arising from this cause is most frequently confined to one side 
of the chest, but even when it exists on both sides, the case cannot 
be confounded with one of ordinary bronchitis, because the crepitus 
is most abundant, not towards the base, but in the upper half of the 
lungs. 

Hemorrhage of the lungs also gives rise to the sub-crepitant 
rhonchus, and, if auscultation be resorted to at the moment of the 
attack, the exact point where the effusion has occurred may some- 
times be discovered. A little later, the blood becoming more dif- 
fused through the bronchia, the sound no longer leads to so exact 
a diagnosis. 

Gurgling. — The characters of this sound, described by many 
authors as cavernous rhonchus, are well indicated by its name. It 
consists of irregular, coarse, and humid " bubbles," few in number, 
and generally associated with cavernous respiration. It is this 
combination which forms its distinctive character. It is audible in 
inspiration, or expiration, or in both, and is loud in proportion to 
the size of the cavity where it originates, and the quantity of liquid 
therein contained. Sometimes it is loud enough to be distinctly 
perceived by the patient himself, and even by his attendants. After 
copious expectoration it ceases, and cavernous respiration is alone 
heard in its place; or it may be suspended, without this substitu- 
tion, in consequence, probably, of the orifice of the cavity becoming 
temporarily closed, but in that case it is renewed by coughing. In 
most cases it exists only in the upper half of one or both lungs. 
Cavities in the lungs, whether due to suppuration, or to gangrenous, 
apoplectic, or tuberculous softening, equally give rise to this sound ; 
but since tuberculous degeneration is infinitely more frequent than 
either of the remaining diseases, the detection of gurgling should 
always be regarded as prima facie evidence of a tuberculous cavity. 
Sometimes a portion of the bronchia becomes so inordinately dilated 
as to possess all the physical attributes of a cavity in the pulmonary 
parenchyma, and to generate gurgling. There are no auscultatory 
signs by which these two conditions can be distinguished with cer- 
tainty ; their diagnosis must be based principally upon the general 
state of the patient, which is rarely so threatening in dilatation of 
the bronchia as in phthisis during the stage of softening. 

34 



398 SEMEIOLOGY. 

Auscultation of the voice. — This method of physical examination 
renders important aid in the diagnosis of thoracic diseases. The 
hand applied to the chest of a healthy person, while speaking, per- 
ceives a distinct vibration ; when the ear is applied in a similar 
manner, not only is the vibration of the walls of the chest per- 
ceptible, but also a buzzing and diffused sound, where the vesicu- 
lar structure is most abundant; a more sonorous, louder, and 
clearer sound, over the large bronchial tubes ; and, over the 
trachea, a reverberation of articulate syllables. These sounds 
become fainter towards the periphery of the lungs, for they are all 
formed in the larynx, and constitute the resonance of the voice. It 
is most distinct where the external coverings of the chest are thin- 
nest, and, as mentioned, where the air-tubes are most capacious. 
Hence it is louder than elsewhere in the axilla, in the space be- 
tween the scapulas, and at the summit of the lungs, both before and 
behind, but on the right more than on the left side, because of the 
greater size of the bronchial tubes in the former region. 

The natural resonance of the voice varies in different individuals, 
depending, not only on the physical condition of the chest, but also 
upon the quality of the voice. Thus, other things being equal, 
the voice resounds but feebly when the chest is deep and capacious ; 
but persons thus formed, have usually a strong, sonorous voice, 
which more than compensates for the impediments to its vibration, 
presented by largely developed lungs, and thick muscular, or fatty 
layers upon the exterior of the thorax. A weak voice, or one of 
high key, resounds but slightly through the chest, even when its 
walls are thin, and its capacity small. So that, in general, the 
natural vocal resonance is loud in the male sex, but weak in the 
female, and in persons of both sexes under the age of puberty. It 
is also feeble in the old, and in them has a degree of tremulousness 
or quivering. . 

In health, the resonance of the voice in the lungs is rarely more 
than an obscure murmur, varying in note and intensity, but never 
becoming articulate, or seeming to be generated directly beneath 
the ear. In disease it has other characters, chiefly depending upon 
the changes which the lungs and pleura undergo, and which ren- 
der them better or worse conductors of sound ; upon the altered 



VOCAL RESONANCE BRONCHOPHONY. 399 

size and shape of the bronchia ; the formation of new cavities ; 
and the modifications of the voice itself. As regards mere loud- 
ness or feebleness of the voice, no more need be said of their causes 
than was mentioned in reference to the corresponding qualities of 
respiration. The more complete the solidity of the lung between 
the point where the sound originates and the ear, the louder will 
be the voice; and on the other hand, the more there is of air, or 
other fluid, in this intervening space, the feebler will the voice be, 
as in pleurisy, pneumothorax, and emphysema. But, as within 
certain degrees the natural resonance of the voice varies conside- 
rably in loudness, no degree of this quality can be regarded as 
morbid so long as it exists generally throughout both sides of the 
chest, whereas a comparatively slight departure from the average 
intensity of the vocal resonance, occurring on one side only, is a 
pretty sure indication of disease. 

Four varieties of morbid vocal resonance are usually described, 
to wit, bronchophony, segophony, pectoriloquy, and amphoric re- 
sonance. Bronchophony is so called, because it takes place in the 
bronchia; it consists of the resonance of the voice in these tubes, 
exaggerated by their dilatation, or the firmness of their walls, or 
conveyed with unusual distinctness to the ear through a denser 
and more uniform medium than is afforded by the healthy lung. 
Sometimes it is loud and clear, like the vibrations of air in a me- 
tallic tube, and sometimes has a shrill and quavering tone, resem- 
bling that of oegophony. It appears, also, to be formed at some 
distance from the ear. This sound is most frequently heard 
over the Jarge bronchial tubes, on the posterior part of the 
chest; when audible in front, its seat is generally in the sub- 
clavicular region. The space in which it is discoverable is often 
sharply defined, and may be very limited, as when heard beneath 
the clavicles, or it may be distinct over a large portion of one side 
of the chest, and especially behind. It is nearly always accompa- 
nied with bronchial respiration, and continues to be heard for a 
longer or shorter time, according to the duration of the disease in 
which it occurs. 

Setting aside dilatation of the bronchia, which it may accom- 
pany, and which is to be recognised by the absence of dulness on 



400 SEMEIOLOGY. 

percussion, and the long continuance of the sound in question 
without febrile symptoms, bronchophony is a sign that the pulmo- 
nary tissue has been rendered abnormally dense by disease. 
Amongst the diseases producing this effect, the most common are 
pneumonia, tubercles, and pleurisy. In the first of these, bron- 
chophony generally exists at the posterior and lower part of the 
lung, is accompanied with fever, and preceded and followed by 
crepitus ; or, if the disease occupy the summit of the lung, the 
acuteness of the attack, fever, and crepitus will be equally charac- 
teristic of pneumonic inflammation. Limited to a small portion of 
the upper lobe of the lung, and combined with haemoptysis, a dry 
cough, progressive emaciation, &c, it indicates tuberculous de- 
posits. In pleurisy, bronchophony is rarely simple, but has gene- 
rally the scgophonic tone to be presently described ; nor does it 
extend much beyond the root of the lung. In pleuritic cases, 
therefore, when distinct and extensive, it very probably depends 
upon a pneumonic or tuberculous complication. 

JEgopho/ty, or the goat-like voice (oaf, ou/os, and pwv^) is " a 
peculiar modification of vocal resonance, distinguished by its tre- 
mulous, nasal, and cracked character, suggestive of the bleating of 
a goat." — (Walshe.) It is an unequivocal sign of a moderate 
pleuritic effusion, of one, that is to say, occupying the lower half, 
or one third of the pleural cavity. In general, if the effusion be 
larger or smaller than this, the sound cannot be detected. Hence, 
it frequently happens, that during an attack of pleurisy, segophony 
is audible at some time during the first few days, then ceases as 
the effusion augments, and returns as it subsides. It is always 
most distinct about the inferior angle of the scapula, and is 
rarely heard beyond the region included between a horizontal line 
drawn at this level and the spine of the scapula, and that only 
when the patient is sitting or standing; if he is made to lie upon 
his face, the voice loses its peculiar tone. Like pure bronchophony, 
it very generally coexists with bronchial respiration. The fore- 
going facts, as well as several direct experiments, combine to prove 
that regophony is due to the vibration of a thin layer of serum in- 
terposed between the lung and the walls of the chest, at a point 
where the large bronchia are superficial. The flattening of these 



JIGOPHONY PECTORILOQUY COUGH. 401 

tubes by compression of the lung is supposed to aid in imparting 
the peculiarity of this variety of vocal resonance. 

Pectoriloquy consists in the more or less complete transmission 
of the articulate voice from the chest to the ear of the observer. 
To be distinctly heard, the stethoscope must be employed, and then 
it seems as if the patient were actually speaking through the in- 
strument. A correct notion of this phenomenon is readily obtained 
by listening to the voice through a stethoscope, one end of which 
is in contact with the larynx of the speaker. Pectoriloquy is rarely 
heard in perfection, except where there is a cavity of medium size 
opening freely into the bronchia, empty, superficial, with dense 
walls, and adhesions of the lungs to the ribs. Evidently, all of 
these conditions can seldom be met with in the same case ; so that 
perfect pectoriloquy is of rare occurrence. In its imperfect form, 
this sign differs but little from bronchophony ; yet it should be re- 
membered that the former is heard in a more limited space, is most 
frequent at the upper and anterior part of the lung, is accompanied 
with cavernous or amphoric respiration, and preceded by gurgling ; 
while the latter is audible over a larger extent, and, towards the 
root of the lung, its accompanying respiration is bronchial, and it 
is associated with mucous rhonchus. 

The form of vocal resonance called amphoric, resembles the 
sound produced by speaking into an empty pitcher. It has a mo- 
notonous, hollow, and metallic tone, and is not articulate. It indi- 
cates an extensive excavation of the lung, or pneumo-thorax ; but 
not necessarily that, in either of these cases, the cavity should com- 
municate with the bronchial tubes. 

Auscultation of the cough. — The signs of pulmonary disease de- 
rived from this source, are of inferior value to all of those which 
have been considered in the present chapter. Their chief utility, 
indeed, consists in their serving to determine the value of the re- 
sults obtained by percussion, and by auscultation of the respiration 
and voice. In coughing, both inspiration and expiration are more 
forcible than natural, and hence the characters of the respiration 
become more marked during these acts, and rhonchi are sometimes 
developed, which, previously, were not detected. The last remark 
is particularly applicable to the discovery of the crepitant rhonchus 

34* 



402 SEMEIOLOGY. 

in the first stage of pneumonia, when a correct diagnosis has a 
most important bearing upon the treatment to be pursued. 

The ear applied to the chest of a healthy individual, while cough- 
ing, perceives a dull and confused sound, which is not of a blowing 
character, but is accompanied with a concussion of the whole chest. 
Both the sound and shock are most distinct, when the ear is applied 
over the larger bronchia. Ausculted over the trachea, the cough 
is hollow and tubular. 

Three varieties of pulmonary cough occur in disease: the bron- 
chial, cavernous, and amphoric. Bronchial cough is difficult to 
describe. It has the characters of bronchial respiration, with the 
harshness and impulse caused by the rapid and forcible passage of 
the air, and is met with under precisely the same circumstances as 
the form of respiration mentioned. Cavernous cough has a hollow 
sound, which strikes upon the ear in a peculiar and often painful 
manner. It is one of the most certain signs of a cavity in the 
lungs. Amphoric cough only differs from the last by its metallic 
tone. It occurs under the same circumstances as the vocal reso- 
nance of the same name. 

Metallic tinkling. — There is another auscultatory sign of tho- 
racic disease which, under certain circumstances, may be heard 
along with movements of the chest, whether occasioned by respi- 
ration, coughing, speaking, or a mere change of the patient's pos- 
ture. It is called metallic tinkling, from its possessing a silvery 
tone, like that produced by striking a metallic or porcelain vessel 
with any small steel instrument, or letting fall into it a grain of sand. 
The conditions essential to its production are a large cavity con- 
taining both liquid and air, and a commotion of the contents of this 
cavity. These conditions are fulfilled in pneumo-hydro-thorax, 
with or without a perforation of the lung, and also in very large 
cavities in the lung containing liquid and air, and opening freely 
into the bronchia. It is thought that, in the latter class of cases, it 
is necessary for the opening of the bronchial tube to be beneath the 
level of the liquid. The mechanism of this sound is not well as- 
certained. Laennec regarded it as the effect either of the agitation 
of the air above the level of the liquid, or of the fall upon the sur- 
face of this latter, of a drop from the upper part of the cavity. 



METALLIC TINKLING PLEURAL FRICTION SOUND. 403 

Others have supposed that the air entering the liquid from the bron- 
chium, or disengaged from it by the movements of the chest, forms 
bubbles, which, in bursting upon the surface of the liquid, produce 
the sound in question. Dr. Williams considers this curious phe- 
nomenon to be due merely to the reverberation of sound, however 
caused, within the cavity. Although, as hinted above, this sound 
is reported to have been heard in close cavities, yet, certainly, in 
the great majority of cases, it is a sign not only of pneumo-thorax, 
but of this disease with a fistulous opening between the pleura and 
the bronchia. 

Pleural friction sound. — In a healthy state, the opposite and 
well-lubricated surfaces of the pleura glide noiselessly over one 
another; but when their smoothness is impaired, their movements 
give rise to a sound which varies a good deal in character, but is 
sufficiently described by the names of its several forms, to wit : the 
grazing, rubbing, grating, and creaking sounds. It is heard most fre- 
quently during inspiration; sometimes during inspiration and expi- 
ration also, but seldom with expiration alone. It is most frequently 
heard at the sides of the chest, where the movement of the ribs is 
greatest, and rarely over a large space. The harsher forms of the 
friction-sound are not only very distinct to the ear, at the point 
where they are heard, but are also accompanied with a vibration of 
the chest, which can be readily felt with the hand, and of which the 
patient is often sensible. Like the exocardial friction-sound, that 
generated in the pleura is due to the attrition of layers of false 
membranes lining the pleura. The more rugged and dry they 
are, the harsher will be the sound resulting from their friction. 
Hence, in the early stage of acute pleurisy, the friction-sound is 
delicate, because the exudation is soft. It is also of short 
duration, because serum soon separates the opposite surfaces 
of the pleura. But when the serous effusion has been so far ab- 
sorbed as once more to allow attrition to take place, the friction- 
sound returns, (provided that the movements of the lung are still 
free,) and has then, in most cases, a rougher and louder sound, 
which is audible during inspiration and expiration. As a sign of 
the progress of pleurisy towards cure, the occurrence of this sound, 



404 SEMEIOLOGY. 

under the circumstances last mentioned, affords ground for a fa- 
vourable prognosis. 

Auscultation of the Larynx and Trachea. — Many of the sounds 
produced in the larynx are audible at a distance, and do not re- 
quire the application of the stethoscope for their detection. Among 
these are the rasping sound of simple laryngitis, the wheezing 
or whistling sound of stridulous laryngitis, croup, cedema of the 
glottis, and obstruction of the organ by foreign bodies or external 
pressure; the croaking sound which may attend most of these 
affections, and which in croup assumes a clangorous tone; and the 
rattling sound, or laryngeal mucous rhonchus, which is so often a 
sign of impending dissolution, as to have acquired the name of 
" death rattle." The chief value of laryngeal auscultation consists 
in its affording an indication of the point affected. Thus, it is alleged 
to be capable of showing the exact place where a foreign body has 
lodged, by the sounds there generated, and also of determining 
whether the false membrane in croup is confined to the larynx or 
extends into the trachea. The method, therefore, may prove use- 
ful in the former case, by informing the surgeon where he should 
operate, and in the latter, by influencing the prognosis. 



PART IV. 
GENERAL MORBID ANATOMY. 

CHAPTER I. 

THE ORIGIN, PROGRESS, AND VALUE OF MORBID 

ANATOMY. 

. Morbid, or pathological anatomy, is that department of medical 
science which treats of the changes produced by disease in the 
solids and fluids of the body. 

Morbid, like normal anatomy, may be studied from two points 
of view. It may be regarded either as an independent science, con- 
versant with dead matter alone, and with the numerous abnormal 
forms assumed by organic texture, as an edifice erected upon 
the ruins of organization, and without any reference whatever to 
vital processes ; — or it may be looked upon as standing in the same 
relation to morbid phenomena and actions, as the anatomy of 
healthy structure does to natural functions. In the latter view alone, 
does it constitute a branch of medicine, for it is only through the 
relation indicated that it influences medical doctrine in regard to 
the seat and nature of diseases, and guides medical practice in 
effecting their cure. . 

The science of morbid anatomy is of modern origin, yet its 
foundations may be said to have been laid by the earliest medical 
writers ; for all of them, with scarcely an exception, refer to changes 
which they supposed to take place in internal organs, and were 
led, doubtless, to that assumption by the evident connexion observed 
by them between structural lesions of external parts and the ac- 
companying symptoms. Thus Hippocrates, or the author of the 



406 MORBID ANATOMY. 

first book, " De Morbis" describes the deposit of tubercles in the 
lungs, the symptoms occasioned by them while in a crude state, 
and those which attend the softening and discharge of these bodies. 
Still, the dissection of the dead was rarely practised by the an- 
cients, and no attempts were made to collate the information de- 
rived from this source by later investigators, until the sixteenth 
century, when the first great work on morbid anatomy, the Sepul- 
chretum of Bonetus, appeared. Even then, the principal object of 
research was the cause of death, an object, when attained, compa- 
ratively barren of instruction ; nor was it until a century after- 
wards, (1772,) that Morgagni announced, and illustrated with all 
his learning and the splendour of his genius, the proper "aim of 
morbid anatomy. To his work upon the "Causes and Seats of 
Diseases" the science of medicine is perhaps more indebted, than to 
any other single agency, for the astonishing progress it has made 
during the last fifty or sixty years. He first pointed out the connexion 
of symptoms with lesions, tracing the parallel between the progress 
of the former and the corresponding changes of structure through 
all their successive phases, and, with a searching analysis, de- 
termined what symptoms and lesions had a real and essential 
relation to one another, as cause and effect. Since the time of 
Morgagni, morbid anatomists have been constantly improving 
upon this system, and labouring, more and more earnestly, to 
render a knowledge of structural alterations subservient to the 
grand objects of medical art, diagnosis and therapeutics. When 
the lesions cognizable by the unaided senses had all been described 
and classified, the cultivators of morbid anatomy still further en- 
larged the boundaries of their survey, by employing the micro- 
scope ; and, not content with tracing out even the minuter forms 
of disorganization in the solids, they separated the constituents of 
the blood, and subjected this, as well as the other fluids, to the still 
more intimate scrutiny of chemical reagents. 

It has been objected to such investigations, that the morbid ana- 
tomist does nothing towards elucidating disease, but only describes 
its ravages, and that it would be as reasonable to conjecture the 
style of a house that had been destroyed by fire, from inspecting 
its ruins, as to seek a knowledge of disease in the disorganization 



THE RELATION OF LESIONS TO SYMPTOMS. 407 

it has wrought. Such cavils betray a want of due acquaintance 
with what has been achieved by morbid anatomy, and an imperfect 
appreciation of what it is capable of effecting. This science not only 
shows the condition of the diseased organ after its injury has pro- 
duced death, but the changes which take place therein, from the 
first moment of its appreciable lesion until it becomes totally unfit 
to perform its function. This it demonstrates in many acute dis- 
eases by means of the various grades of textural change which exist 
in the same organ, between the part which still retains its healthy 
qualities and that which has departed most completely from its origi- 
nal condition. In other acute maladies it establishes a relation between 
lesions and symptoms, by comparing them together in cases 
which have proved fatal in various stages. Finally, in chronic dis- 
orders, which, at different periods of their course, have been sud- 
denly terminated by some accident or intercurrent disease, it ex- 
hibits similar gradations of structural alterations, and analogous 
connexions between them and the attendant symptoms. No one 
doubts the necessity of following with care every successive change 
of structure which takes place upon the surface of the body, even 
when it is admitted to be a merely local manifestation of a disease 
involving the whole economy, such as gout, rheumatism, syphilis, 
cancer, eruptive fevers, &c. ; it may, therefore, well excite sur- 
prise that any should regard the study of internal morbid lesions with 
indifference or distrust, merely because they are hidden from view, 
and on that account more difficult of detection. Lesions, whether 
internal or external, are symptoms, and not the less so because 
they are themselves the causes of other symptoms: from this very 
circumstance they acquire a superior importance. If, then, they 
constitute a part of the phenomena of any disease, to deny that an 
acquaintance with them is unnecessary in the practice of medicine, 
is equivalent to asserting that there is no need of understanding a 
disease, in order to treat it skilfully. 

But it is further objected to the cultivation of morbid anatomy, 
that oftentimes dissection reveals no lesion whatever, capable of 
explaining either the fatal termination, or the symptoms observed. 
M. Louis has well remarked, that cases of this sort "are precisely 
those which prove, in the most evident manner, the indispensable 



408 MORBID ANATOMY. 

necessity of this branch of science ; since if all the viscera had 
not been examined with scrupulous care, we could not have been 
certain that there was no serious lesion which would explain both 
the symptoms and the unfortunate termination of the case." To 
reject this negative proof would be as unphilosophical as to refrain 
from studying the symptoms of diseases, because, under certain 
circumstances, many disorders run through their course in a latent 
form, — and would involve the injustice of supposing that absolute 
perfection is claimed for the means now employed to investigate 
morbid changes. Ten years ago, the anatomical characters of 
affections, which later examinations of the blood have rendered 
familiar, were entirely unknown ; and it cannot be doubted that 
methods yet to be devised, will reveal an essential connexion be- 
tween diseases now called functional, and positive physical lesions. 

Since anatomical lesions constitute no less really a part of dis- 
ease than symptoms, properly so called, it follows that a knowledge 
of both must render diagnosis much more precise than either one 
alone. If no other evidence of this proposition were attainable, it 
would be sufficient to point to the errors of diagnosis which are 
daily committed, and which are only shown to be errors by the re- 
sults of post mortem examinations. These mistakes, however, fall 
chiefly under the notice of those who cultivate morbid anatomy, 
and it may, therefore, be proper to point out some of the other par- 
ticulars in which this department of science has assisted in perfect- 
ing diagnosis. 

Morbid anatomy has shown that symptoms are not phenomena 
grouped by mere accident in a particular manner. It has revealed 
the links which bind them together, or rather the source from which 
they flow. No human sagacity could have explained why one group 
of symptoms attends pneumonia, and another phthisis, unless the 
physical alterations of the solids and fluids, in each disease, had 
been ascertained to be different. The discovery of the law 
which connects symptoms and lesions, led to the minuter study and 
record of the former, in order to their subsequent comparison with 
the results of dissection, and their reference to the changes of struc- 
ture in which they severally originated. As symptoms began to be 
vnore carefully recorded, arid more severely analyzed, the impor- 



INFLUENCE IN LOCALIZING DISEASE. 409 

tant truth dawned upon the medical world, that diseases of a very 
dissimilar nature, although similar in their prominent features, had 
for centuries been confounded under the same name, and ignorantly 
subjected to the same treatment. Paralysis, for example, formed 
a distinct disease ; whereas it is now regarded only as a symptom 
common to various structural lesions of the nervous centres, rup- 
ture, inflammation, softening, pressure, &c. Little or no distinc- 
tion was made between pleurisy and pneumonia, or between the 
former of these and muscular rheumatism of the chest. All in- 
flammations of the bowels were included under a common name, 
and the peritoneum supposed to be commonly involved when the 
mucous membrane of the intestine was affected ; whereas it is now 
known that the serous and mucous tunics of this organ are rarely 
involved in the same disease. Above all, there was a large class 
of continued fevers, of which the names of but two or three can 
still be traced in medical treatises, all of the rest having been found 
to depend upon inflammation of some one or more organs, and es- 
pecially of the brain. From these discoveries it resulted that more 
attention was paid to local symptoms, and consequently to local 
treatment, while diseases almost ceased to be regarded as entities, 
as malicious demons which had taken possession of the patient, and 
began to be viewed as mere modifications of organic structure and 
vital phenomena, differing only in form, and not essentially, from 
the growth, acts, and habits of the individual. 

In the order of development, the physical methods of explora- 
tion could not fail to follow closely upon the localization of disease s 
since the latter directed attention to the organs which were now re- 
cognised by the symptoms as the seats of disease. By these methods., 
especially in pulmonary and cardiac affections, the physician is 
enabled, as it were, to see through the body of his patient, and to 
announce precisely what alteration of structure exists at the point 
which he examines. Without morbid anatomy, he could never have 
known that the friction-sound of the heart, or pleura, is a sign of 
pseudo-membranous exudation ; that the harsh valvular murmur 
continuing after complete convalescence from acute articular rheu- 
matism, is an almost infallible token that the patient will ultimately 
die of disease of the heart ; that dulness on percussion, and harsh 

35 



410 MORBID ANATOMY. 

respiration under one clavicle, is an almost certain announcement 
of consumption ; that segophony makes known the existence of an 
effusion in the pleural cavity ; or that palpitation of the heart de- 
pends as well upon disorders of the blood and nervous system, .as 
upon organic disease. These are but a few examples of the in- 
valuable additions made by morbid anatomy to medical diagnosis. 

The advantages conferred by morbid anatomy upon therapeutics 
are not less real, although less obvious, than those which have 
been enumerated ; for, if to treat a disease skilfully it must be un- 
derstood, nothing can be plainer than that every step which is 
taken towards perfect diagnosis, is one also towards successful 
treatment. Morbid anatomy not only shows that in some affections 
there are prominent lesions whose nature it is either to remain 
stationary or to augment, and consequently dissuades from the 
employment of any but a palliative treatment in such disorders ; 
it shows that in other disorders a cure can be effected in no other 
way than by a certain destruction of parts, and the arrangement 
of those remaining in new relations, and therefore warns the phy- 
sician against active interference; it proves that, in still other ma- 
ladies, a certain time must necessarily elapse before the restoration 
of the injured part to its original condition, and hence accounts for 
the continuance of certain symptoms, and counsels patience and 
moderation in the management of the case. Thus, too, it often 
checks unreasonable and false pretensions to the performance of 
wonderful cures; for when imperfectly educated physicians assert 
that they have cured in a few hours a disease in which the morbid 
anatomical element continues unchanged for several days at the 
least, there can be no doubt either that the narrators are wanting 
in good faith, or that they have been mistaken in their diagnosis. 

Morbid anatomy not only throws light upon the diagnosis of 
diseases actually existing, but it reveals the laws which govern the 
development of diseases, and hence foretells distant and hidden re- 
sults. The case of valvular transformation, already mentioned, is 
one in point. Another, and still more striking, illustration of the 
same truth is afforded by the law of tubercular development dis- 
covered by M. Louis, that " if after the age of fifteen years we find 
tubercles, or gray semi-transparent granulations, in any organ, 



INFLUENCE ON THERAPEUTICS AND PROGNOSIS. 411 

they exist at the same time, and in a still more advanced stage, 
in the lungs." Chronic peritonitis, occurring subsequently to the 
age of puberty, is always tubercular, hence under the law just 
quoted, that disease is always connected with tubercles in the lungs. 
Of this fact M. Louis remarks : " I have more than once recog- 
nised and announced the existence of phthisis in cases which ex- 
hibited all the symptoms of chronic peritonitis, but in which auscul- 
tation and percussion did not indicate any appreciable lesion of the 
parenchyma of the lungs, and even in individuals who did not 
cough : — a diagnosis which some persons will call presumptuous, 
which, however, was not so, and which I could not avoid making, 
without denying the laws of the economy of the disease, the science 
itself, in fact ; for of what does the science consist but of these 
laws?" 

Finally, and not to dwell unduly upon this subject, important 
though it be, morbid anatomy teaches that as the different textures 
of the body have different modes of organization and growth, so, 
also, they are subject to different diseases ; so that the same tissue 
in remote parts of the body is liable to identical morbid alterations. 
Hence, to know the seat of a disease is also to know its probable 
course, and the local changes which it will occasion. Everywhere 
serous membranes secrete fibrin, and tend to form unnatural ad- 
hesions ; everywhere mucous membranes tend to secrete pus, and 
to become unnaturally thick, &c. 



CHAPTER II. 

METHOD OF CONDUCTING POST-MORTEM EXAMINATIONS. 

The almost total neglect of the subject of morbid anatomy in 
many of the principal schools of the United States, renders neces- 
sary some account of the manner of examining dead bodies, in 
order to profit by their inspection. Not a few, indeed, are 
" opened," as the phrase is, but seldom, unless some obscurity in 
the course of the fatal disease, excites the curiosity of the medical 
attendant, or alarms the fears of surviving friends ; and even then 
it is too commonly the fashion to proceed at once to the presumed 
seat of the disease, and having detected a supposed sufficient cause 
of death, to abandon further dissection as useless. It may safely 
be said that if anatomists in general had contented themselves with 
such superficial inquiries, the science of morbid anatomy would not 
yet exist, and that so long as it is thus slightingly prosecuted 
amongst ourselves, we must be content to hold a very subordinate 
rank in the medical republic. The cultivation of this department 
demands unusual devotion, enthusiasm, and perseverance ; private 
practitioners can do little more than contribute an occasional addi- 
tion to its stores, which must be mainly enriched by physicians 
attached to public institutions. Even these, if they have not been 
taught by a competent instructor, must grope long in obscurity, 
seeing without understanding, and describing much erroneously or 
imperfectly, and be content, also, to devote many hours of severe 
and disgusting labour, to obtain a very moderate degree of profi- 
ciency. Yet, at no smaller cost than this, can the science of me- 
dicine be improved. The following directions may appear superflu- 
ous to most of those who have paid attention to the subject, but, if 
strictly complied with, will probably be found to promote economy 
of time and labour, and increase the profit to be derived from 
dissections. 



EXAMINATION OF DEAD BODIES. 413 

Amongst the assistants present at the dissection, one should be 
charged with writing down whatever may be dictated by the prin- 
cipal operator, and, in order that the record may be readily referred 
to, and nothing omitted in the examination, an uniform rule of 
procedure should be adopted, and all parts of the body thoroughly 
inspected. The clothing of the operator should be protected by an 
apron with sleeves, and his hands anointed with oil, which prevents 
their retaining an unpleasant smell. 

The date of the examination is first to be noted, with the time 
that has elapsed since the patient's death, and the state of the 
weather, as these circumstances may influence the degree of change 
occurring subsequent to death. In recording the appearance of the 
exterior of the body, its degree of emaciation should be stated, and 
any local tumidity which may exist, particularly of the abdomen, 
for if this contains air extricated after death, by putrefaction, less 
confidence must be placed in the changes of colour and consistence 
of internal organs, as evidences of disease. The limbs generally 
grow stiff when the body becomes cold, and the joints do not re- 
cover their pliancy until putrefaction has commenced ; this rigidity 
is most strongly marked in cold weather, and in the bodies of per- 
sons who have died of acute inflammatory diseases. Its degree 
should be noted. All discolorations of the skin should likewise be 
recorded, whether such as arise from disease, cutaneous eruptions, 
wounds, bruises, &c, or those which depend upon the blood gra- 
vitating to the part on which the body happens to have lain since 
death. The latter are most usually found upon the back and sides, 
and sometimes on the neck, head, and genitals, giving the skin a 
purplish or marbled appearance, to which the term sugillation has 
been applied. This discoloration is distinguished from ecchy- 
mosis by its being confined to the capillary tissue of the skin, while 
extravasation of blood, from blows received during life, exists 
in the subcutaneous tissue chiefly. Sugillation is most frequently 
seen when, from any cause, the blood remains fluid after death, 
and this happens in malignant febrile diseases, and typhus, after 
death from lightning, and in extremely hot weather. 

If the dissection is intended to be complete, (and in the present 
description that is taken for granted,) the brain is next to be exa- 

35* 



414 MORBID ANATOMY. 

mined. This is commenced by an incision from ear to ear, over 
the top of the head, and dissecting these flaps so as to turn them, 
the one over the face, and the other upon the neck. If it is not 
intended to preserve the body, an easier method is to make an in- 
cision at right angles with the first, and extending from the root of 
the nose to the occipital protuberance. The calvarium is then re- 
moved by sawing through it, as nearly as convenient to the base 
of the skull, making the incision anterior to the ears form an ob- 
tuse angle with that through the occiput, so that when the bone is 
replaced it may not slip from its position. Great care must be 
taken that the saw do not wound the soft parts within the skull, 
an accident which may be prevented by not sawing entirely 
through the bone at all points, and by using a dull-edged chisel as 
a lever to complete the removal of the skull-cap. 

The dura-mater is then opened by two parallel incisions, one on 
each side of the middle sinus, and extending from the crista galli 
to the posterior incision through the skull, after which the grand 
falx may be removed by detaching its anterior connexion with the 
ethmoid bone. The condition of the meningeal veins, the amount 
of fluid in the cavity of the arachnoid, the flatness or proper con- 
tour of the convolutions of the brain, the character of the effusion 
into the pia-mater, the adhesion, if any, of this membrane to the 
surface of the brain, the existence of tumours or abnormal produc- 
tions of any kind within the cavity of the cranium, should all be 
passed in review. The brain is then to be examined by removing 
successive slices of its substance from above downwards, proceed- 
ing cautiously as the ventricles are approached, so that the amount 
of fluid contained in them may be justly estimated. The colour, 
consistence, &c, of the cerebral tissue are at the same time to be 
observed. 

At this stage the remainder of the brain may be removed by 
raising its anterior lobes, cutting through the nervous trunks as 
they enter their respective foramina in the skull, dividing the ten- 
torium where it is attached to the edges of the petrous bone, the 
rido-es which guard the lateral sinuses, &c, and then introducing 
a scalpel into the spinal canal, and cutting off the spinal marrow 
as low down as possible. The central portions of the brain, the 



EXAMINATION OF DEAD BODIES. 415 

cerebellum, and the membranes covering both, should then be mi- 
nutely examined in every part. 

The neck and the great cavities of the trunk are next to be 
opened. Some anatomists prefer that these should be examined 
before the cranium, but without assigning any sufficient reasons for 
their preference. To inspect the pharynx, and its connexion with 
the larynx, a vertical incision must be made, extending from the 
mouth to the upper edge of the sternum, and the lower jaw sawn 
through at its symphysis; or, what answers the purpose equally 
well, the attachments of the tongue and pharynx to the circuit of 
the lower jaw, the hard palate, and the base of the skull, divided 
by an elliptical incision, and the parts drawn out by the hand 
while they are set free from their posterior and lateral connexions. 
The mucous membrane of the pharynx, the state of its follicles, 
that of the epiglottis, of the edges of the laryngeal opening, the 
vocal chords and the aperture between them, the mucous mem- 
brane of the larynx, its cartilages, &c, should be examined after 
this latter organ has been opened, by a vertical incision passing 
through the angle of the thyroid cartilage. 

To open the thorax and abdomen, the integuments are divided 
from the top of the sternum to the pubis, and the flaps dissected 
from the ribs to a line a little beyond that of the junction of the 
ribs with their cartilages ; or, when neatness is not imperative, 
lateral incisions may be made along the edge of the false ribs to 
either side of the body. The cartilages are then divided as near 
their costal articulations as possible, and the attachments of the 
diaphragm and mediastinum having been severed, the sternum is 
disarticulated from the clavicles, care being taken not to open the 
subclavian veins. The lungs and pericardium are in this manner 
exposed to view. 

The heart is first to be examined. The pericardium is slit open, 
and the quantity, colour, &c, of its fluid contents, if any, the con- 
dition of its lining membrane, noted, and the origin of the great 
vessels observed. The latter are then divided as far as possible 
from the heart, this organ being drawn gently forwards at the 
moment, and the characters of the blood which escapes remarked. 
The finger is then passed into the large arteries to feel if the valves 



416 



MORBID ANATOMY. 



are pliant, and water poured into them to ascertain whether they 
fulfil their office ; a similar procedure should be instituted in the 
case of the auriculo-ventricular valves. After opening and in- 
specting the auricles, their capacity, thickness of their walls, con- 
dition of their septum, and fibrinous or other contents, the ven- 
tricles are conveniently opened by a longitudinal incision, extending 
from the apex to the outlet of each. This is readily made by in- 
troducing one blade of a pair of scissors into the aorta or pulmo- 
nary artery, and cutting forwards through the anterior surface of 
the heart, and parallel to the ventricular septum. The thickness 
of the walls is to be carefully measured, exclusive of the columnar 
carneee, and at several points between the base and apex ; their 
power of resisting force is likewise to be noted, with the colour, 
pliability, incompleteness, adhesions, &c, of the valves. It should 
be remembered that these organs, as well as the lining membrane 
of the arterial system, when stained with dark blood, soon acquire 
a vivid colour on being exposed to the air. 

After removing the heart, the pleura is examined, and its con- 
tents, adhesions, and condition noted. If the case be one in which 
a perforation of the lung is suspected, the pleural cavities ought, 
even before dissection of the heart, to be filled with water, and the 
lungs inflated, when, if there be any aperture upon their surface, 
the air escaping from it will bubble up through the liquid. In 
other cases, the most satisfactory mode of examining the lungs is 
to remove them both, along with the trachea, from the chest, which 
can be done by dissecting the trachea from its connexions first, 
and drawing upon it while severing the vessels, &c, about the 
roots of the lungs. The pulmonary tissue is then felt, to learn 
whether it crepitates and is permeable to air, or any portion of it 
is hardened : in the latter case the part should be incised and mi- 
nutely examined, so as to learn the nature of the substance occa- 
sioning the hardness. The bronchia are next laid open to their 
remotest extremities, by means of probe-pointed scissors ; the state 
of their mucous membrane, and that of the secretion contained in 
them, their deviation, if any, from the usual diameter, and their 
communication with cavities, if these exist, are all to be recorded, 



EXAMINATION OF DEAD BODIES. 417 

together with the size, position, contents, and connexions of the 
latter. 

The greater number and complexity of the abdominal organs, 
render an examination of them somewhat difficult. After ascer- 
taining the condition of every part of the peritoneum, its liquid con- 
tents, the general development of the intestinal canal, the condition 
of the mesenteric glands, the relations of tumours, if any, to the 
adjacent organs, in situ, the next step is to remove the intestinal 
canal. In order to prevent the escape of its contents, a double liga- 
ture is applied at the commencement of the jejunum, and another 
at the caput coli, and the intestine divided between the two threads 
at each point, and then an oblique incision being made along the 
root of the mesentery, the whole of the small intestine, except the 
duodenum, is at once removed ; thus affording room for subsequent 
operations, and allowing the stomach and colon to be readily taken 
away. The mesentery is next divided by numerous cuts perpen- 
dicular to the bowel ; so that this latter, instead of hanging in loops, 
forms a straight tube. The bowel should be divided longitudinally 
by the enterotome, (or large blunt-pointed scissors, having one blade 
longer than the other,) along the attachment of the mesentery, so as 
not to cut through the glands, which are, for the most part, seated 
upon the free side of the intestine. The stomach and colon are to 
be treated in a corresponding manner ; the character of the con- 
tents of these cavities is to be particularly noticed ; the colour, thick- 
ness, and resistance, of their mucous membrane, at different points, 
carefully tested ; search made for ulcerations, enlargement of the 
secernent follicles and glands ; and every deviation from the natu- 
ral state of the parts accurately described. 

The spleen, the biliary organs, with their ducts, the pancreas, 
the kidneys, ureters, and bladder, and, lastly, the internal organs 
of generation in the female, are all to be examined ; the solid 
organs by numerous incisions with the scalpel, and the interior of 
the hollow viscera laid open with probe-pointed scissors, or by the 
enterotome. 

Finally, the spinal marrow is to be inspected. The spinal canal 
is most conveniently opened by laying bare the spinous processes 
of the vertebrae in their whole extent, and sawing through on each 



418 MORBID ANATOMY. 

side the bony bridge from which these processes project. A chisel 
and mallet perform the work rather more expeditiously, but with 
greater risk of wounding the parts within the canal. The same 
method is to be pursued in examining the spinal marrow and its 
membranes, as was recommended in the case of the encephalon. 

The following points should be constantly borne in mind, and 
noticed, in relation to every organ that is dissected ; although, as 
will be seen, all are not equally applicable to every organ. 1st. 
The position and connexion of organs, and the morbid deposits 
which exist upon or within them. 2d. Their dimensions, shape, 
weight, and density, or degree of hardness. Under this head are 
included all comparisons to familiar objects, as seeds, eggs, nuts, 
&c. ; a mode of estimation much inferior to that of referring these 
qualities to known standards of weight, measure, and shape. The 
form of the surfaces, whether concave or convex, puckered, &c. ; 
of the edges, whether sharp, serrated, indented, &c. 3d. The de- 
gree of cohesion possessed by the molecules of an organ ; its elas- 
ticity and toughness ; whether its divided surfaces are smooth, 
granular, fibrous, or splintered, according as they are torn, broken, 
or cut ; and the degree of adhesion of membraues to subjacent parts. 
4th. The colour, polish, and translucence of organs ; the colour 
of their proper tissue, divested of its outer covering ; the shade of 
colour, and whether it resists washing, and the depth to which it 
extends. It is important to know that a small quantity of diluted 
blood gives a pale yellowish or greenish tinge to white tissues, 
which ought not to be, as it often is, mistaken for the hue of jaun- 
dice or that of pus. The colour of concentrated bile closely re- 
sembles that of thin blood. Putrid blood is of a dirty or raspberry 
red colour. 5th. The contents of organs, their quantity, colour, 
viscidity, smell, chemical reaction, and variety ; and, 6th, the pro- 
portions of the elementary constituents, whether fibrous, cellular, 
vascular, or the peculiar normal tissue of the organs, with any ab- 
normal or heterologous deposit which may be present. 



CHAPTER III. 

OF THE CHANGES PRODUCED BY DISEASE IN THE NORMAL 
CONSTITUENTS OF THE BODY. 

The morbid conditions which form the subject of pathological 
anatomy, are divided into two great classes, one of which com- 
prises all the changes and transformations affecting the solids and 
fluids of which the body is naturally composed ; and the other those 
morbid deposits and growths which " penetrate amongst the pre- 
viously existing elements of the body," having a composition and 
mode of growth different from these latter, and not arising, as was 
formerly supposed, from a transmutation of the normal tissues. 
These two classes will be considered in the present and following 
chapters. 



SECTION I. 

OF THE BLOOD IN DISEASE. 

As all the tissues originate in the blood, and grow by the mate- 
rials which it furnishes, the morbid relations of this fluid have a 
primary claim to be examined. It is not uncommon for writers of 
the present day to speak of the importance now attached to the 
morbid states of the animal fluids, as indicative of a return to the 
old humoral pathology ; but, in doing so, they confound things es- 
sentially different. The humoral pathology adopted in the Hippo- 
cratic writings, and servilely followed in succeeding ages, was a 
pure hypothesis, which, as was stated in another place, assumed 
that the body was composed of four humours, whose various com- 
binations produced diseases. These combinations were, at the com- 
mencement of the seventeenth century, estimated by Sanctorius at 






420 MORBID ANATOMY. 

eighty thousand ! In the last century or two, much, indeed, was 
said of the acridity and putridity of the blood, and some imperfect 
notices of the physical changes occurring in that fluid were re- 
corded. But there is little analogy between the views now enter- 
tained, concerning the influence of the blood in disease, and those 
speculative notions which ruled so long in medicine. The ancients 
not only imagined the humours, but also their qualities and effects. 
With inquirers of the present day, the subject is simply one of ob- 
servation, experiment, and induction. If here and there a medical 
chemist, impelled by the force of genius, and elated by the wonder- 
ful results of his favourite science, overleaps the bounds of legiti- 
mate reasoning, and wanders in the trackless field of speculation, 
but few among the more eminent pathologists are tempted to follow 
his erratic course. The soundest thinkers receive his revelations 
with distrust. There is in fact a general unwillingness to adopt 
them as settled principles, until they have been tested by men of 
large experience in studying and treating disease ; by men who re- 
gard the animal economy as something more than a machine, and 
the stomach as something different from a chemical retort ; who 
recognise in it a vital chemistry, and vital dynamics, governed by 
other laws than prevail amongst the instruments of the laboratory 
and the workshop. 

The morbid relations of the blood, investigated in the spirit which 
alone could lead to valuable results, are still very imperfectly 
known. MM. Andral and Gavarret, Simon, and MM. Becquerel 
and Rodier, are indeed almost the only original authorities whom 
it is profitable to consult upon the composition of the blood in dis- 
ease, and all of these have published their researches within the 
last ten years. The memoir of the last-named gentleman, as being 
the most recent and complete, will be especially referred to in the 
following pages. 

It is difficult to ascertain the composition of perfectly healthy 
blood, because few persons will submit to be bled without believing 
themselves sick ; and hence the nearest approach to what may be 
employed as a standard, whereby to judge of the changes of this fluid 
in disease, is that obtained by the depletion of those who are either 
suffering from plethora, but otherwise in perfectly good health, or 



THE BLOOD IN HEALTH, AND IN PREGNANCY. 421 

of those who desire to lose blood in the spring, as a measure 
of precaution against fulness of the circulation. Analyses of the 
blood of such persons, have shown that there is a striking diffe- 
rence in its composition in the two sexes. The following are the 
results of MM. Becquerel and Rodier. In 1000 parts there are, 
on an average, of 











Males. 


Females. 


Water 


. 


, , 


. 


779 


791-1 


Globules . 


. 


. . 


. 


141-1 


127-2 


Albumen . 


, 


, , 


. 


69-4 


70-5 


Fibrin 


. 


. 


, 


2-2 


2-2 


Extractive matters 


and free 


salts 


6-8 


7-4 


Fatty matters 




. 




1-600 . 


1-620 



These results differ chiefly from those previously obtained, in the 
proportions of the globules, of which the average was stated by 
Andral and others at 127; but this has been attributed, by the 
writers quoted, to a neglect of the difference between the two sexes ; 
a difference, we repeat, bearing almost exclusively upon the pro- 
portion of globules. 

Pregnancy, although a physiological condition, induces remark- 
able changes in the composition of the blood. It has long been 
known, that a degree of plethora sometimes accompanies this state, 
which requires, for it is relieved by, depletion. When, however, 
the blood of pregnant females came to be examined, it was found 
to be generally impoverished : that is, to contain a diminished pro- 
portion of globules. The same observers who determined this fact, 
also concluded from their experiments in cases of plethora uncon- 
nected with pregnancy, that in plethora the proportion of globules 
is increased, and that the symptoms of the affection depend upon 
this increase, and not on any augmentation of the mass of the blood, 
as was previously believed. They found, therefore, the fact, that 
pregnant females are subject to symptoms of plethora, one of dif- 
ficult solution. As will be presently shown, the proportion of glo- 
bules in plethora is not increased, and the plethoric symptoms de- 
pend upon over-distention of the vessels. This distention may 
take place under any circumstances of the composition of the 
blood ; and that it does occur in pregnancy, is abundantly proved 

30 



422 MORBID ANATOMY. 

by the turgidness of the vessels and all the tissues, the headache, 
disorders of vision, heaviness, vertigo, &c, which sometimes at- 
tend it. But when blood is drawn from a pregnant female, it is 
found that the mean proportion of the globules does not exceed 
112-6, and that this change becomes more marked as gestation 
advances. At the same time, the quantity of fibrin either remains 
normal, or is slightly augmented. Pregnancy, then, is allied to 
plethora as well as to anemia. In it these two conditions may ac- 
tually coexist, if the meaning of the latter is restricted, as it usually 
is, to a deficiency in the proportion of globules in the blood. 

No matter what the disease in which the blood has been exam- 
ined, this fluid has uniformly been found to undergo some change. 
The proportion of fibrin varies according to the nature of the dis- 
ease ; but, independently of this condition, certain changes rarely 
fail to take place. These are, a marked diminution of the globules; 
one, less in degree, of the albumen of the serum ; and an increase 
of the fatty matters, particularly of the cholesterin. It is not easy 
to decide whether these alterations of the circulating fluid are owing 
directly to the disease in every case, or to the diet which, in acute 
affections, cuts off the supply of nutritive materials, and, by sus- 
pending digestion, makes smaller demands upon the liver, and 
allows the cholesterin to be retained in the blood. In chronic mala- 
dies, alterations of the blood take place more slowly, but are, on 
the other hand, more complete. In either class of disorders, the 
changes are greatly hastened by depletion ; after each bleeding, the 
blood grows more watery, and its globules are sensibly diminished, 
but its fibrin undergoes no change. Becquerel and Rodier give the 
average quantities of the several elements of the blood in persons 
who had been bled three times. In these cases the proportion of 
globules fell from 129-2 to 99-2. 

The authors just mentioned have established, by their experi- 
ments, that the iiletlwric condition, and the symptoms incident to 
it, are probably the effect of an increase in the mass of the blood, 
and in nowise of any change in its composition. The average pro- 
portion of globules found by them in six cases of well-marked ple- 
thora, in males, was 138, or rather less than the normal average. 
MM. Andral and Gavarret found the average, in thirty-one plethoric 



PLETHORA AND ANEMIA. 423 

persons, (sex not mentioned,) to be 141, or precisely the average 
for healthy blood obtained by Becquerel and Rodier. If, then, this 
latter number be admitted to be correct, it is clear that the blood 
undergoes no change of composition in plethora, and the symptoms 
of the disorder can only be referred to the excessive quantity con- 
tained in the vessels. 

By anemia is generally meant a condition marked by paleness 
of the tissues, torpor of the digestive functions, palpitations, dys- 
pnoea, a bellows' murmur in the cervical vessels, &c. In this af- 
fection, taking chlorosis as its type, MM. Andral and Gavarret 
determined that the proportion of globules is considerably below 
the normal standard. But as in regard to plethora, they fell into 
the error of attributing the symptoms of the disorder to an excess 
of globules, so, on the other hand, they equally erred in regarding 
the phenomena of chlorosis as due to a deficiency of globules alone. 
There are, in fact, two sorts of cases comprised under the head of 
anemia. They have in common the anatomical character, de- 
ficiency of globules ; but in one, the mass of the blood is aug- 
mented, and in the other, diminished. The former often accom- 
panies chlorosis ; the latter results from frequent and profuse losses 
of blood, or other fluids of the economy, the slow poisoning of 
saturnine emanations, protracted intermittent fevers, scanty and 
unwholesome food, living in dark and ill-ventilated places, and, in 
general, whatever slowly exhausts the system. In none of these 
cases, except chlorosis, does plethora occur, but on the contrary, a 
permanent diminution of the mass of the blood. It was from analy- 
ses of the blood of thirty-five chlorotic persons, that MM. Becque- 
rel and Rodier drew the following averages : 

Water 824 

Globules 94-7 

Albumen 68 

Fibrin 3-5 

Extractive matter and salts - 8 

Fatty matter 1-806 

Tn every one of these cases depletion was called for by plethoric 
symptoms, and gave decided relief. It will be observed that in the 
above table the deficiency of globules is exactly compensated for 



424 MORBID ANATOMY. 

by the excess of water, the other constituents of the blood remain- 
ing nearly unaltered. It is further to be noticed, that the mean 
'proportion of globules there given, affords no precise notion of the 
extreme alterations of this element by disease. There are cases 
of chlorosis in which the proportion of globules is but little, if at 
all, depressed. There are others, again, in which it has fallen 
from 127 to 28, according to MM. Andral and Gavarret. These 
authors mention a case of excessive metrorrhagia in which the 
globules formed but 21 out of 1000 parts of blood. Dr. Frick 
mentions a case of anemia in which the proportion of globules had 
fallen to 14. The patient was a female, and for three years had 
laboured under the disease, which followed an attack of malarious 
fever.* 

The fibrin of the blood remains unchanged in the affections 
marked by an altered proportion of globules, yet it is, of all the 
elements of the blood, the one most frequently modified by disease, 
because affected by both of the two classes of maladies which are 
oftener met with than all of the rest united, inflammations and fevers. 
Inflammation appears to be always productive of an increase in the 
fibrinous element of the blood, just as the opposite condition, ex- 
isting in adynamic affections, seems to diminish it. The operation 
of these antagonizing causes is well seen in typhoid fever compli- 
cated with inflammation of the lung. The blood of the patient 
which, before the appearance of the intercurrent malady, was found 
deficient in fibrin, and therefore imperfectly coagulable, immediately 
afterwards shows an excess of this element, and that not only by 
analysis, but also by the formation of a buffy coat. The average 
proportion of fibrin in inflammatory diseases may be stated at 6, 
and the range of this element between 4 and 10£. The degree of 
its increase is directly proportioned to the extent and activity of the 
inflammation, and the constitutional reaction, a fact which, as well 

* " Of the Relative Proportions of the different organic and inorganic Ele- 
ments of the Blood, in different diseases. By Charles Frick, M. D., of Balti- 
more." Am. Jour, of Med. Sci., January, 1848. This excellent paper, which 
gives a strong impression of its author's industry and skill, we trust is only the 
forerunner of many original essays by the same, and other American hands, 
in the rich field of humoral pathology. 



CHANGES IN THE FIBRIN AND ALBUMEN. 425 

as the more general one stated in the preceding sentence, is proved, 
not only by a comparison of the result in particular cases with the 
standard proportion, but also by direct analysis of blood taken from 
the same individual before and after the development of the inflam- 
matory attack. The diseases in which the greatest amount of 
fibrin has been detected in the blood are pneumonia and acute arti- 
cular rheumatism. As already mentioned, bleeding does not tend 
to diminish the proportion of fibrin ; hence the relief which so often 
follows the operation, in acute disorders of an inflammatory type, 
must be attributed to some other cause than a reduction of this ele- 
ment, which cannot, therefore, as some conjecture, be regarded as 
the source, but only as a consequence of the accompanying morbid 
state. 

The class of diseases in which the fibrin of the blood falls below 
the normal standard comprises all of those in which the blood 
drawn from a vein coagulates imperfectly, or, as was said in former 
times, is in a state of putridity or dissolution. Of this sort are 
typhus, typhoid and miasmatic fevers of low grade, including yel- 
low fever and the plague, also contagious febrile diseases such as 
variola, scarlatina, rubeola, and glanders; together with the state 
produced by infection of the blood with pus, the matter of dissection, 
the venom of serpents, &c. In mild cases of such affections the 
fibrin can scarcely be said to have diminished, but in the more se- 
vere, and particularly in those which terminate fatally, the blood 
shows no disposition whatever to coagulate, and its proportion of 
fibrin may not exceed one part in a thousand. This alteration of 
the blood appears to explain the occurrence of hemorrhages, con- 
gestions of internal organs, petechias, &c, which are so common 
in the complaints referred to. 

Besides the increased proportion of fibrin which all recent ob- 
servers admit to be characteristic of inflammatory diseases, MM. 
Becquerel and Rodier have pointed out two other changes which 
occur in these affections, to wit, diminution of the albumen, and 
increase of the cholesterin, the latter being usually twice as abun- 
dant as in health. The bearing of these facts can, at present, be 
only conjectured. 

The albumen of the blood is diminished in granular disease of 

3(i* 



426 MORBID ANATOMY. 

the kidneys, and dropsy connected with certain diseases of the 
heart. It is supposed that the escape of albumen by the kidneys 
is the cause of the falling off in the proportion of that element of 
the blood. 

The suppression of a secretion is often followed by an accumu- 
lation of the essential ingredients of that secretion in the circulating 
fluid : thus urea and cholesterin are abundant in the blood when 
they are no longer duly evacuated through the kidneys and liver, 
but the latter substance appears to be sometimes generated in ex- 
cess, and to abound in the blood, producing general jaundice, while 
there is at the same time a copious discharge of bile from the 
bowels. 

The peculiarities in the coagulation of blood drawn from a vein 
have long been regarded as important to be studied ; the results of 
analysis, which have been stated above, aid materially in interpret- 
ing these peculiarities. Blood obtained by venesection usually 
separates into two parts, a disc-shaped mass called the clot or coa- 
gulum, and a yellowish serum in which it floats. The process 
sometimes begins within a minute or two after the blood is drawn, 
and sometimes not for fifteen or twenty minutes, and is generally 
attributed to the influence of the atmospheric oxygen.- A case 
lately occurred to the writer in which this contact appeared to de- 
termine the coagulation of blood which had remained fluid for 
several hours. On dissecting the body of a person who had died of 
the low typhus fever which prevailed during the autumn of 1847, in 
a district inhabited by the lowest class of negroes, the blood was 
quire fluid although death had taken place from six to eight hours 
before, but when allowed to stand in a cup, or in the chest whence 
the lungs had been removed, it speedily formed a dark and mode- 
rately firm coagulum. 

The size, shape, and colour of the clot are worthy of attention. 
It consists chiefly of fibrin, containing more or less serum, and 
globules. In diseases of a low or adynamic type, the blood coagu- 
lates imperfectly, or not at all. If any clot is formed, it is volu- 
minous, extending across the vessel in which the blood is received; 
its edges are not elevated, it is often very soft and loose, forming 
a slightly consistent gelatinous mass like currant-jelly, which 
breaks up at the slightest touch ; in extreme cases no true clot is 



CHARACTERS OF THE CLOT. 427 

formed, but only a few flocculent coagula. in such blood the prin- 
cipal alteration is deficiency of fibrin, the other elements remaining, 
for the most part, normal. The clot of inflammatory affections, on 
the other hand, is usually cupped, tough, and firm, yellow upon 
the surface, and red towards the bottom, where the globules accu- 
mulate. Here the fibrin is in excess, the other elements remain- 
ing normal. 

From these illustrations it may be inferred that the existence of 
fibrin in the blood produces its coagulation, and that fibrin forms 
the yellow or bufFy coat of the inflammatory clot. But it has been 
ascertained that the bufFy coat is very far from being the index of 
inflammation alone, or from constituting an indication for depletion, 
as was formerly supposed ; that it may exist in pregnancy, ane- 
mia, and chlorosis, in all conditions, namely, in which there is a 
deficiency of the globules, while the fibrin remains unchanged. 
Hence it appears that it is the quantity of fibrin relatively to that 
of the globules, and not the positive quantity of the former, which 
occasions the bufFy coat. The fibrin may even be somewhat in 
excess, yet, if the globules are abundant, as when slight inflam- 
mations attack the plethoric, there will be no bufF, but the clot will 
be broad, thick, moderately firm, and saturated with serum. 

Jt should not, however, be supposed that the presence or ab- 
sence of the bufFy coat infallibly shows that any of the above- 
mentioned relations between the fibrin and globules exist in a 
given case. ,The globules, being specifically heavier than the 
fibrin, subside to the lower part of the clot, and favour the forma- 
tion of a bufFy coat, when coagulation proceeds with only a mode- 
rate degree of rapidity. But that degree may not exist in the par- 
ticular case; causes which cannot be discovered heighten or lessen 
it ; others influence it which are better known. Thus if the blood 
flows in a small stream, there will be a succession of small coagula, 
and not one large clot; or if it falls into a cold and shallow vessel, 
the same blood will have no bufFy coat, which, directly afterwards 
received into a warm bowl, will present a well-marked bufF. 

The tough, white, and sometimes partially organized coagula 
which are frequently found in the heart after death, are probably 



428 MORBID ANATOMY. 

formed before this event ; their density, freedom from globules, 
and their structure, are inconsistent with any other supposition. 

Several substances foreign to the blood are occasionally found 
in it. One of these is sugar, which has, however, been detected 
in one disease only, diabetes mellitus. Pus is of more common 
occurrence in the circulating fluid, and is either generated within 
the vessels, or enters them from without. Andral found pus glo- 
bules in the blood in a case of adynamic fever, with numerous 
abscesses of the solid organs; in another of a wound of the leg, 
terminating fatally in three days ; and in a third of psoas abscess, 
with purulent collections in both lungs. In the last case, many 
globules of pus were found in the right, and some in the left ven- 
tricle of the heart, showing that they had passed through the 
lungs. The same pathologist found that fresh pus mingled with 
blood, in a glass vessel, had no perceptible influence upon it, not 
even preventing its coagulation; while putrid pus, on the other 
hand, destroyed in a few hours both the globules and the fibrin of 
the blood. If decomposed pus, or rather its ammoniacal product, 
have such an effect when directly mixed with the blood, and if, as 
is probable, a similar product forms the basis of the deleterious 
emanations from the bodies of the dead, and of the sick when 
crowded together, an explanation is afforded of the type assumed 
by diseases in hospitals, jails, ships, &c, of which the principal 
anatomical character is fluidity of the blood. So destructive to 
fibrin is the formation of pus, that an excess of this element in the 
blood, produced by an abscess with inflammation, will disappear, 
and the blood lose its power of coagulating, if the contents of the 
abscess become putrid and infect the system. 

Next to alterations in the composition of the blood, the varieties 
in its distribution require consideration. There are several de- 
grees of activity attending the local increase of blood in the vessels. 
In the lowest, the increase takes place in obedience to merely phy- 
sical laws; in the next, the blood is determined to a part by a vital 
power ; in a still higher grade, it is not only so determined, but is 
held there permanently, and produces more or less permanent 
changes in the structure of the part; these conditions, which are 



STASIS AND CONGESTION. 429 

called, respectively, stasis, congestion, and inflammation, will be 
now summarily reviewed. 

Stasis, stagnation, and passive congestion, are synonymous 
terms, implying that the vessels of a part contain an excess of 
blood, in consequence either of weakness of the propelling force, 
or of an obstacle to the exit of blood from the congested organ. 
It is very apt to occur in states of constitutional debility, during or 
immediately after attacks of disease, in very young and very old 
persons, and at a distance from the heart. Its mechanical causes 
are, 1st, the mere weight of the blood, when the circulation is 
feeble. Hence this cause, along with the partial dissolution of the 
blood, occasions ecchymoses in dependent parts of the body, dur- 
ing fevers of a low type, and accumulations of blood in the poste- 
rior part of the lungs, when feeble persons lie upon the back. It is 
passive congestion, also, which frequently gives rise to hemor- 
rhoids and varicose veins of the legs, in persons accustomed to sit 
or stand for a long time together. 2d, An obstacle in or near the 
right side of the heart, preventing the return of the venous blood to 
that organ, causing distension of the veins, and giving the skin a 
bluish or purple hue, as in cyanosis. 3c?, The compression of one 
or more venous trunks by a tumour or ligature; from this cause 
varicose veins arise in pregnant females, in whom the uterus com- 
presses the iliac vessels ; from this, also, the sense of fulness in 
the head, injection of the face and eyes, &c, when tight cravats 
are worn, or an aneurism presses upon the jugular veins ; from 
this, too, when the hepatic circulation is obstructed, hemorrhoids 
arise. 

Congestion, properly so called, active congestion, or determina- 
tion of blood, is a very different condition from the last. It is due 
immediately to the altered action of the capillaries, and remotely 
to some vital and, therefore, unintelligible change; while the form 
just described affects the veins chiefly, and depends wholly on physi- 
cal or mechanical causes. It is most apt to occur in nervous, feeble, 
and irritable persons, the mass of whose blood is probably below 
the normal standard, and in organs the most abundantly supplied 
with blood-vessels and nerves, and of great functional activity. It 
takes place in the capillary rcte or network, where secretion and 



430 MORBID ANATOMY. 

nutrition are performed, and animal heat is generated ; where, in 
fact, nearly all organic changes, whether natural or morbid, are 
carried on. This determination of blood forms the first step in the 
true inflammatory process, and, in a greater or less degree, pre- 
cedes hypertrophy, atrophy, and many forms of hardening, soften- 
ing, and transformation of the several tissues. Not that congestion 
is demonstrable, or can be proved necessary, in every instance of 
structural lesion, or that its connexion with the lesion produced can 
always be explained ; this process, however, does precede the de- 
velopment of many organic changes, apparently unlike, and even 
the opposites of one another, and is therefore often assumed to have 
been present, after the development of the consequences to which 
it usually gives rise. 

Although active congestion depends immediately upon causes 
existing within the part where it takes place, yet those causes would 
often remain inoperative, but for the occurrence of passive conges- 
tion in the same part. Thus, when cold drives the blood from the 
surface of the body upon the internal organs, if any one of them 
is weaker than the rest, it will very probably remain gorged with 
blood; its functions will at first be impaired, and, after a time, 
may be completely suspended. Thus, in congestion of the brain, 
the earliest symptoms may be no more than an unusual throbbing 
of the carotid and temporal arteries, than an unwonted activity of 
the senses, a keen perception of light and sound, excitement of the 
mind, sleeplessness, quickened play of the imagination, and irrita- 
bility of temper. At a later period, the functions of the brain grow 
sluggish, the senses are dull, the intellect inert ; there is drowsiness, 
heaviness, and sometimes convulsive disorders. 

The consequences of congestion are, hemorrhages, fluxes, drop- 
sies, inflammation, and disorders of nutrition. 

Hemorrhage. — Blood cannot escape from the capillaries without 
their laceration. Supposed exudations of blood are composed of the 
serous portion, tinged with the colouring matter of this fluid. Ef- 
fused blood is either coagulated or fluid ; it is usually in the latter 
state, when it proceeds from the capillaries, and in the former, 
when its source is in the larger vessels. According to Vogel, when 
blood escapes into the intestinal canal, the fibrin remains fluid, while 



HEMORRHAGE FLUX. 431 

the albumen is coagulated by the free acid of the gastric juice, and 
encloses the blood-globules, which lose their red colour, and assume 
a blackish-brown tint. 

The causes oflaceration of the vessels, and consequent effusion, 
are very numerous, and may be referred to several heads : 1st, di- 
rect violence; 2d, erosion of the coats of the vessels by caustics, 
the mortification, suppuration, or softening of tumours, and the 
softening of the coats themselves, or rather of atheromatous de- 
posits formed within them ; 3d, pressure of the blood from within, 
in consequence of an impediment to the circulation. It is evident 
that the last-named cause will operate with greater readiness when- 
ever a cause belonging to either of the other classes is already in 
action. 

Effused blood may be entirely removed by absorption, and that 
very rapidly, provided that it remain fluid. When, however, a clot 
is formed, the more fluid parts are taken up, and the coagulated 
fibrin undergoes changes which will be pointed out under the head 
of inflammation. 

The effects of hemorrhage depend upon the quantity of blood 
which escapes from the vessels. When this is considerable, death 
may at once ensue, or the functions of the whole system be disor- 
dered. In smaller quantity, extravasation of blood produces local 
injury; the rupture of the fibres of the organ where it takes place, 
as in apoplexy ; the compression of the constituents of an organ, 
as in pulmonary apoplexy and effusion into the pleura or pericar- 
dium ; a direct interference with the proper function of an organ, 
as when the blood fills up the pulmonary vesicles and bronchia, 
or coagulates in the ureter or urethra, preventing the escape of 
urine; and, finally, inflammation and its consequences, in the af- 
fected part. 

Flux, which is regarded as another consequence of congestion, 
is a superabundant secretion from the skin, the mucous membranes, 
or from the glands connected with these latter. Such are exces- 
sive discharges of mucus, serum, or bloody fluid, (serum dyed with 
the colouring matter of the blood,) from the bowels ; of sweat 
from the skin ; of saliva, bile, or urine, from their respective or- 
gans, &c. 






432 MORBID ANATOMY. 

Dropsies generally proceed from congestion or inflammation ; the 
more fluid parts of the blood transude through the walls of the ves- 
sels, but instead of being discharged externally, accumulate in the 
several serous cavities of the body, in the cellular tissue, or in ac- 
cidental membranous sacs, forming encysted dropsies. Mechanical 
congestion is the most frequent cause of dropsy. It may be produced 
in the lower extremities (oedema) by the pressure of the uterus in 
pregnancy, or by surgical bandages and apparatus injudiciously 
applied ; and it has been created artificially in the lower animals, 
by tying certain of the large venous trunks. So, too, when the 
liver is contracted, or atrophied, (in cirrhosis,) there is congestion 
of the abdominal veins, and frequently dropsy. Aneurisms or other 
tumours, near the heart, may, by compressing the ascending vena 
cava, produce anasarca, and effusion into the serous cavities of the 
belly and chest. An analogous state of things occurred in a case 
reported by Dr. Watson, of London, where the superior vena cava 
was found obliterated after death. The patient was dropsical only 
in the upper half of the body. " His arms were so highly ana- 
sarcous that he could not bring them near his sides ; his neck and 
face were hideously bloated and exaggerated, and his eyes promi- 
nent and staring, while his lower limbs were of their natural size, 
and looked preposterously out of proportion." But dropsy takes 
place, not only in consequence of venous congestion, but along 
with capillary, arterial, or active congestion, and even inflamma- 
tion. Thus, a person in profuse perspiration, exposed to a cool, 
moist atmosphere, may rapidly become anasarcous from head to 
foot. ; or if he is recovering from scarlatina, may be attacked with 
ascites; or he may have serous effusion resulting from inflamma- 
tion of any of the serous membranes. In the present state of our 
knowledge, there is no means of explaining how these dissimilar 
causes produce a seemingly identical effect. 

The fluid of dropsical effusions is not the same in all cases. 
Sometimes it contains a large proportion of dissolved fibrin, which, 
coagulating, forms false membranes in cavities, and an interstitial 
deposit in parenchymatous organs; sometimes, on the other hand, 
the fluid is simply serous. The cases of the former kind are 
nearly all due to inflammation, and constitute the class of fibrinous 



THE FLUID OF DROPSIES. 433 

dropsies. The effused fluid, as stated, generally coagulates within 
the body, but it sometimes preserves the liquid form until removed 
artificially, and then coagulates. This fluid is supposed to be 
extravasated chiefly by the capillary vessels, while that of serous 
dropsy permeates the walls of the veins almost exclusively. 
These two forms have been only of late distinguished from one 
another. 

The fluid of dropsy was formerly supposed to be identical with 
the serum of the blood, but the analyses of MM. Andral and Ga- 
varret have shown the incorrectness of this opinion. In sixteen 
cases of serous dropsy examined by them, the highest proportion 
of albumen in the effused liquid was 48, and the lowest 4, the ave- 
rage proportion of serum in the healthy blood being 70. These 
observers did not find that, the seat of the effusion made any sen- 
sible difference in the proportion of albumen. The state of the 
constitution, however, influenced it; the less the strength of the 
patient, the less the albumen, and vice versa. Thus in six cases 
of hydrocele, the subjects of which were all in robust health, the 
proportion of albumen varied between 35 and 59 ; and when, in 
dropsy of the larger cavities, tapping was performed several times, 
it was found that the quantity of albumen in the fluid evacuated 
progressively declined. The proportion of water in dropsical effu- 
sions was found to vary between 950 and 986, the normal average 
in the blood being 790. All of the cases of dropsy here alluded 
to were due to venous congestion from mechanical causes. Had 
they arisen from inflammation, it is probable that the proportion 
of coagulable matter in the effused fluid would have been greater ; 
since, as the authors alluded to remark, it is found to be so in the 
fluid obtained from the skin by vesication. 

The preceding statements furnish the positive proof of what has 
long been alleged, that the blood is impoverished in dropsy, and 
show that its impoverishment is due to a loss of albumen, and in 
some cases of fibrin. Confirmatory negative evidence of this pro- 
position is to be found in the fact that a decline in the proportion 
of neither of the remaining chief constituents of the blood, fibrin 
or red globules, without that of albumen, ever produces a similar 

37 



434 MORBID ANATOMY. 

result, for dropsy does not exist either in chlorosis, or in fevers 
and affections of a typhoid type, except as an unusual compli- 
cation. 

SECTION II. 

INFLAMMATION. 

There is but little difference between the physical phenomena 
of active congestion and of inflammation, except that the latter are 
more complete and permanent. When an irritant is applied to the 
web of a frog's foot examined under the microscope, the current 
of the blood through the vessels is at first increased in size, and 
its movements quickened, but, after a time, there is a slower move- 
ment of the blood, and at last its complete stasis. In this experi- 
ment, the red globules, which at first are observed to occupy the 
centre of the vessels alone, and are readily distinguishable from 
one another, by degrees fill the whole channel, «nd become so 
closely aggregated as to form, apparently, a homogeneous mass, 
in which the individual globules can no longer be distinguished. 
At this stage exudation takes place; a thin serum first permeates 
the walls of the vessels, and then one of somewhat greater tenacity, 
which is known as coagulable lymph, but in its composition and 
vital properties is identical with fibrin. In this substance, blood- 
globules gradually form, and open channels, which are new ves- 
sels intended for the organization of the recent fibrinous deposit ; 
after which it is either absorbed, transformed, or else converted 
into pus. 

This description, meagre as it is, comprises all of our positive 
knowledge of the mechanism of inflammation. Of the agents 
which cause more blood than usual to flow into the part, which 
regulate the enlargement and constriction of the vessels, which 
bring on effusion of serum and fibrin, and produce the subsequent 
changes of this latter, much has been written, very much conjec- 
tured, but nothing settled. The microscopical phenomena of in- 
flammation, however, explain satisfactorily those which common 
observation has determined to belong to this process, at least in 



MECHANISM OF INFLAMMATION. 435 

parenchymatous structures. There is first, in the inflamed part, 
an afflux of blood, whence arise redness, slight swelling, and heat, 
also, because the development of animal heat is directly propor- 
tioned to the activity and fulness of the circulation; then hardness, 
and increased swelling from the effusion of serum and fibrin into 
the surrounding cellular tissue; a sense of tension, weight, and 
pain, from the pressure of this effusion, particularly upon the ner- 
vous branches enclosed within it. The increased pulsation of the 
arteries leading directly to the affected part appears due simply to 
the obstruction of the channels through which blood usually circu- 
lates with freedom, while the same, or even an augmented force, 
continues to imj.el it. 

Serous or fibrinous effusion may, to some extent, be looked 
upon as a termination of inflammation, because, when copious, the 
symptoms of reaction subside. The subsequent action of this pro- 
duct depends upon its situation, upon the circumstance of its find- 
ing a direct and ready exit from the system, or of its being con- 
fined in the cellular tissue, or in serous cavities, constituting 
various forms of dropsy. In certain situations the effusion is apt 
to produce serious consequences, as when it is poured into the pa- 
renchyma of the lungs, or into the cellular tissue about the glottis, 
causing suffocation. In general, the more copious and extensive 
effusions, if due to inflammation at all, are owing to a low grade 
of this action ; very active inflammation, on the other hand, more 
commonly occasions a deposit of tenacious fibrin within or upon 
the affected part. Thus slow and moderate inflammation of the 
peritoneum distends it with a limpid and watery fluid, but after 
violent and rapidly fatal inflammation this membrane is more com- 
monly dry, or covered with fibrin or pus. 

Inflammation presents somewhat different features according to 
the structure which it attacks. The more important of these mo- 
difications are the following. In the cellular tissue there is swell- 
ing, hardness, diminished cohesiveness, a tendency to limit the 
action by the formation of abscess, or, according to the peculiarity 
of the constitution, to perpetuate the effects of that action by a new 
organization. In the nervous tissue, and especially in its great 
centres, inflammation produces softening and disorganization, 



436 MORBID ANATOMY. 

sometimes with great rapidity, and sometimes with extreme slow- 
ness. In the former case there is usually suppuration ; in the 
latter, a gradual destruction of the part, which may be converted 
into a sort of paste, or a still thinner fluid. Inflammation of the 
arteries is a cause of gangrene in the parts supplied by them, in 
consequence of their channels being obstructed with fibrinous con- 
cretions. The veins when inflamed are sometimes obliterated by 
adhesion, sometimes they suppurate, or the coagula formed in them 
are converted into pus, which is carried by the circulation into 
distant organs, and may there give rise to abscesses, called metas- 
tatic. When this event does not take place, the coagula may be 
gradually removed, or else remain permanently, converting the 
vessel into a hard cord. The lymphatic vessels, or rather the 
ganglia connected with them, tend, when inflamed, either to sup- 
puration or induration, in which latter state they may remain for 
an indefinite length of time. 

Inflammations of the skin form an extensive class of diseases, 
whose distinguishing features depend upon their being seated in 
different parts of this extremely complex structure. The minute- 
ness and intimate connexion of its several parts render the study 
of their morbid alterations extremely difficult. According to M. 
Cazenave, the simple exanthemata, (of Willan and others), are 
seated in the vascular network of the skin, and are true inflam- 
mations, producing, according to circumstances, exfoliation of the 
cuticle, serous, or purulent effusions, &c. Vesicular eruptions are 
regarded by M. Cazenave as affecting principally the sudiparous 
glands; pustular eruptions as seated in the sebaceous or other folli- 
cles : papular affections as involving principally the papillary bo- 
dies; squamae as a hypertrophy of the epidermis; and tuberculous 
affections as a hypertrophy of the fibrous element of the true skin. 

Mucous membranes are, more than any others, subject to in- 
flammatory diseases, and present the peculiarities of these affections 
in a striking manner. Redness is found in them of every shade, 
from a light rosy tint to a dark brown. This colour is sometimes 
uniformly diffused over a considerable surface, and sometimes ex- 
ists in small spots. It is never absent in acute attacks, but is often 
so in chronic diseases of this system. Its presence is generally 



INFLAMMATION IN VARIOUS TISSUES. 437 

inferred, rather than visible, in internal inflammations. It is seen 
in affections of the conjunctiva, and of the lining membrane of the 
mouth, pharynx, nostrils, rectum and vagina during life, and in 
those of the air-passages and intestines after death. In the first 
stage of inflammation the mucous membrane becomes unusually- 
dry, and unirritating liquids placed upon it are rapidly absorbed. 
Subsequently an increased quantity of mucus is secreted, and the 
glands, whose excretory ducts open upon the inflamed surface, 
bathe it with an unwonted flow of their peculiar fluids. The mucus 
becomes more tenacious and opaque, and of a whitish or milky, 
and sometimes of a yellowish or greenish hue, or, if the inflamma- 
tion is violent, the discharge is streaked with blood, or mingled 
with pus. As the affection declines, the secretion grows thinner, 
and of a lighter colour, and either returns to its normal condition, 
or continues in a chronic form, undiminished in quantity. In some 
acute mucous inflammations the effusion is fibrinous, and is either 
thrown off in shreds, as in certain forms of diarrhoea and dysentery, 
or may, when discharged, preserve the tubular form of the organ 
in which it was secreted. This latter phenomenon is observed 
chiefly in pseudo-membranous croup. No satisfactory reason can 
be assigned why mucous membranes should at one time secrete 
mucus and at another fibrin. 

When a mucous membrane has been long inflamed, it sometimes 
becomes attenuated, and is readily torn ; but, in most instances, it 
grows thicker, and its surface is uneven, mammillated, and covered 
with a stratum of tenacious mucus. The opposite surfaces of a canal 
lined with this membrane never adhere, but it is often reduced in 
size by effusions of fibrin in the sub-mucous cellular tissue, forming 
strictures, of which examples are most frequently found in the rec- 
tum and urethra. Loss of substance in a mucous membrane, by 
ulceration, or otherwise, is repaired by a new formation which the 
cellular tissue beneath furnishes. This new membrane is usually 
slow to regain the structure and functions of the original tissue, and 
ofren, indeed, fails entirely to do so, but remains smooth and com- 
pact, like a scar upon the skin. Although ulceration frequently 
attacks the mucous membrane where it exists in its simplest form, 
yet the mucous follicles are its most ordinary seat, particularly in 

37* 



438 MORBID ANATOMY. 

the small intestine. Ulcers in this situation are more likely than 
others to penetrate deeply, and sometimes they pierce even the 
peritoneal coat. In mucous inflammations, the glandular organs, 
whose ducts open on the inflamed surface, are very generally af- 
fected ; their secretion is at first augmented, and subsequently their 
structure may become involved. Thus, when the mouth is in- 
flamed, the salivary glands secrete an increased quantity of saliva ; 
when the stomach or duodenum is similarly affected, more bile 
than usual is secreted. Inflammations of the bladder, and urethra, 
and of the solitary and agminated crypts of the small intestine, are 
not uncommonly attended with a like condition of the kidneys, 
testicle, and mesenteric glands, respectively. 

Serous membranes, when inflamed, are but slightly, if at all, 
thickened ; their apparent increase of thickness depends, in almost 
every instance, upon the false membrane which covers them. 
The sub-serous cellular tissue always participates in their inflam- 
mation, and indeed shows the first signs of this process. It becomes 
inordinately vascular, its meshes are then distended with a serous 
fluid, some of which penetrates the substance of the investing mem- 
brane, causing it to swell slightly, and lose its transparency. Red 
patches appear here and there upon the free surface of the mem- 
brane, extending in every direction, and at last coalesce. The 
most intense redness has usually been found after a violent and 
rapid attack of inflammation ; in such a case, as before remarked, 
the membrane is quite dry, and has a sticky feel. More commonly 
vascular injection is less marked, and the effusion more abundant. 
The exhaled fluid varies both in kind and quantity. Often it is 
limpid, and seems composed only of watery serum ; after active 
inflammation it is more generally turbid or milky, holding in sus- 
pension shreds of fibrin, or possessing all the characters of thin 
pus. On other occasions it is nearly gelatinous, and may exist in 
this form between the layers of the serous membrane. Occasion- 
ally it contains blood. Its odour may be foetid, but is in most 
cases slightly sweetish or nauseous. In some instances of menin- 
gitis, pure pus is effused upon the surface of the membrane, with- 
out either serum or fibrin ; the same fact has been observed, but 
more rarely, in pleurisy and peritonitis. The quantity of the ef- 






INFLAMMATION IN VARIOUS TISSUES. 439 

fusion varies according to the violence of the inflammation and its 
seat. It is of course less, other things being equal, in the smaller 
serous cavities, that of the arachnoid for example. In subacute 
and chronic inflammations its amount is generally greatest. 

The effused fibrin, in serous inflammations, is at first soft, in 
consequence of its containing serum; but the latter is gradually 
absorbed, while the former becomes more tenacious, and by de- 
grees glues together the opposite surfaces of the membrane, when- 
ever it is interposed between them. Gradually this bond of union 
grows firmer, and the organ whose movements were originally fa- 
cilitated by the lubrication of its serous investment, is now impeded 
in its motions, bound down in one position, and by the contraction 
of its adventitious covering, forced to occupy a narrower space 
than before. Thus robbed of its liberty, its functions are liable to 
be impaired, and the general health of the patient to suffer in pro- 
portion to the importance of the affected organ in' the economy. 
The fibrin, thus effused and solidified, usually becomes organized 
by the extension into its substance of the capillary vessels supply- 
ing the membrane beneath it, and it in the end assumes the charac- 
ters of condensed cellular tissue, or undergoes the further transfor- 
mations to be pointed out hereafter. 

Effusion of fibrin is not always to be deprecated. On the con- 
trary, it sometimes forms the only obstacle to a speedily fatal issue 
of disease. When the pleura is perforated by the softening of a 
tubercle, or the peritoneum by an ulcer of the bowels, the rapid 
effusion of fibrin may close the opening, and prevent further mis- 
chief. Such a secretion, as is well known, is excited artificially in 
attempting the radical cure of hydrocele. By its means, the oppo- 
site surfaces of the tunica vaginalis testis become adherent, and the 
cavity of this sac is obliterated. 

In the fibrous system, the lesions due to inflammation are not 
well ascertained. In the sclerotica, for example, besides vascular 
injection, and perhaps attenuation of the membrane, none others 
are clearly made out. In the fibrous tissues which form invest- 
ments for the bones, and connexions between them, thickening, 
softening, and the secretion of fibrin, which is readily transformed 
into bony matter, are the principal changes known. The cartilages 



440 MORBID ANATOMY. 

and fibro-cartilages, when inflamed, are affected with redness, soft- 
ening, and erosion. But all of the tissues mentioned in this para- 
graph, possess a very low degree of vitality, and not unfrequently 
appear unchanged while the soft parts around them are completely 
disorganized. Inflammation of the bones may be confined to the 
periosteum, as already noticed, or it may affect the medullary mem- 
brane, or finally the osseous structure. In both of the latter cases, 
there is usually enlargement of the bone, with closure of the me- 
dullary canal, ulceration, or necrosis. 



SECTION III. 

ALTERED NUTRITION. 

The process' of growth is essentially the same in all organized 
structures. Even inorganic bodies, to a certain extent, come under 
the same law. Every solid is originally derived from a fluid. The 
inorganic by the mere precipitation and amorphous or crystalline 
accretion of the denser particles contained in the primary fluid ; the 
organic by the generation within this fluid of new substances. In 
animals this fluid is fibrin. It is effused by the blood-vessels into 
the parenchyma of every organ, and, according to the influences 
acting upon it, adds to every tissue in its own kind, or produces 
substances different from any of the normal tissues. 

It is one of the greatest of the many mysteries of life, that a 
fluid of apparently uniform composition should generate so many dis- 
tinct and dissimilar products ; that from the very same fibrin, muscle 
should be formed in one place, and in another, brain, bone, or glan- 
dular structure. An attempt has been made to explain this won- 
derful phenomenon, by supposing that parts already formed exert, 
such a control over the fibrinous matter, in contact with them, as 
to determine the nature of its subsequent product. But this hy- 
pothesis is evidently inadequate to explain the original formation of 
the several tissues, and cannot therefore be accepted to account for 
their growth ; for we are not warranted in assuming different causes 



THEORY OF NUTRITION. 441 

to operate in the deposition of the first, and of the second and sub- 
sequent particles, of the several tissues. 

If the powers which regulate normal nutrition are obscure, .those 
which cause the production of new substances are still more inex- 
plicable. Here, evidently, the supposed influence of already ex- 
isting particles must be altogether null, since, from the common 
generative fluid, substances arise differing in every respect from the 
normal constituents of the body. To explain this inconsistency of 
the hypothesis above referred to, some pathologists invoke an altered 
state of the blood. This fluid, say they, has lost its natural com- 
position, and, consequently, the same causes no longer produce on 
its exudation the same effects as in health. Hence, according to 
the particular alteration of the blood, cancer is deposited in some 
cases, and in others, tubercle, &c. But, if this be so, we are en- 
titled to ask, why such deposits do not take place in all parts of the 
body ; for if their formation is owing to an alteration of the blood 
alone, there appears to be no good reason why they should not be 
formed indifferently in any or all of the tissues and organs. 

Leaving, as unprofitable, any further discussion in regard to the 
proximate causes of normal and abnormal nutrition, we shall re- 
gard it as settled, according to the present state of our knowledge, 
that in all forms of this process the new product is derived from 
fibrin exuded by the blood-vessels ; from fibrin alone, whenever the 
product is similar to one of the normal tissues ; from fibrin of a 
modified character, when the product is unlike any of those tissues. 
The first class of the disorders of nutrition will be treated of in the 
present chapter. Of these, one of the most common, as well as 
important, is 

Hypertrophy. — This term signifies excessive nutrition. It is, 
indeed, a process which differs from healthy nutrition only in de- 
gree. It consists in the augmentation of one or more of the natu- 
ral constituents of an organ, in such a manner that the newly 
formed parts are continuous with those already existing, and can- 
not be anatomically distinguished from them. Before the cultivation 
of textural morbid anatomy, it was customary to speak of an organ 
increased in bulk as hypertrophied, without reference to the element 
especially affected. It must be evident, however, that the latter 



442 MORBID ANATOMY. 

point is the one really important to be known. To describe the 
liver as being enlarged or hypertrophied, is of little consequence, 
unless it be also stated whether its augmented bulk is due to in- 
crease of the glandular structure, to sanguineous congestion, or to 
the deposit of fibrin, fat, tubercle, or some other substance, in the 
interstitial structure of the organ. 

As hypertrophy, in its restricted and proper sense, is only an 
exaggeration of a natural state, it is impossible to draw a distinct 
line between that degree of enlargement which does not affect the 
health, and which has been called physiological, and that which, 
being greater, engenders disease, and is termed pathological hyper- 
trophy. These terms are merely relative. A heart which is of 
normal size in a tall and robust man, would be regarded as hyper- 
trophied in a delicate female. An increase of muscle which would 
only add to the power and grace of a limb, would be a fatal dis- 
ease, if it took place at the pylorus. Simple hypertrophy, without 
change of consistence, generally afTects the essential part of an 
organ ; the muscles, in the case of the heart ; the glandular struc- 
ture in that of the liver, &c. 

Augmented bulk may be accompanied with induration or soften- 
ing. The former is a frequent consequence of inflammation, and 
of the organization of exuded fibrin. In that case there is not a 
true hypertrophy, but an increase of bulk, owing to an adventitious 
deposit, and in reality an atrophy of the proper tissue of the organ, 
produced by the pressure of the effused fibrin. Hypertrophy of an 
organ, when excessive, interferes with adjacent organs by com- 
pressing them ; thus, by enlargement of the liver the stomach is 
compressed, and the lungs are unable fully to expand. 

Nearly all the tissues are liable to hypertrophy. The muscles 
of animal life, however much developed, never seem to exceed the 
physiological limits of relative size; for a corresponding develop- 
ment takes place at the same time in the bones, ligaments, and 
other accessory parts, by which is preserved that original and just 
harmony which is the characteristic of health. Excessive nutrition 
of the muscles of organic life readily assumes a morbid character. 
Nature has so delicately arranged the internal mechanism of the 
body, that even a slight increase of size or force in any portion of 



HYPERTROPHY. 443 

it may be attended with serious consequences. Of the involuntary 
muscles, those of the heart are most frequently hypertrophied, 
occasioning all the results which are attributable to an undue ac- 
tivity of the circulation. Among these the various forms of active 
hemorrhage are conspicuous. The worst consequences of hyper- 
trophy of the heart are those which result from its complication 
with valvular disease of the same organ, or with aneurism of one 
of the large vessels in its neighbourhood. 

The muscular coat of the hollow organs is often greatly thick- 
ened. That of the bladder sometimes measures nearly half an 
inch in thickness. This hypertrophy is due to any cause that ob- 
structs the flow of urine, and obliges the bladder to make strong 
expulsive efforts. The increase of the uterus during gestation, 
although more apparent than real, (its bulk depending very much 
upon the fluids it contains,) is nevertheless a real hypertrophy, for 
it is only in the impregnated state that the arrangement and extent 
of the muscular fibres of the uterus can be demonstrated. The 
muscular coat of the stomach, especially around its pyloric orifice, 
is sometimes considerably thickened in old persons. When this 
opening is obstructed by cancerous or fibrous tumours, the mus- 
cular tissue of the rest of the stomach is remarkably increased. 

Enlargement of the glandular organs, in consequence either of 
a true hypertrophy of the secernent cells, or of an interstitial de- 
posit of fibrin, is of very common occurrence. The liver, the 
prostate, mammary, lymphatic, and thyroid glands, all present 
remarkable instances of this phenomenon. Enlargement of the 
spleen, the ordinary consequence of intermittent fever, depends 
upon an interstitial effusion of fibrin. The brain itself may grow 
inordinately. This seems to be usually a congenital affection, or 
at least to occur at an age when it can hardly be attributed to 
the influence of external stimuli. 

Mucous membranes sometimes become thickened from chronic 
inflammation ; but in general the contraction of canals lined by 
this tissue is due to a layer of fibrin in the subjacent cellular tissue. 
The skin is frequently thickened from similar causes. Its several 
constituents, the derm, the rete, the hair-bulbs, the sebaceous fol- 
licles, may each be separately increased. The epidermis, which 



444 MORBID ANATOMY. 

is a product of secretion, is sometimes changed from a delicate 
transparent membrane into a hard, yellowish, and opaque sub- 
stance, which assumes the form of scales, and when thus covering 
a large part of the body, forms one of the most revolting spectacles 
that can be conceived. 

Physiological hypertrophy often takes place when one of two 
symmetrical organs has been disabled. This is almost constantly 
the case in regard to the mammse, kidneys, and testicles. 

Atrophy ; or diminished nutrition, is exactly the reverse of the 
condition just described, but is more generally a morbid operation. 
Thus, when general, which hypertrophy never is, it surely indi- 
cates the presence of disease, except where directly caused by 
starvation. Any disorder of the digestive apparatus which pre- 
vents the food from being properly converted into chyme or chyle, 
or subsequently opposes the absorption of this latter, must occasion 
atrophy. Of such causes are chronic inflammation of the intes- 
tines, and disease of the mesenteric glands. A more obscure set 
of causes are those which, either by preventing the deposit of new 
matter in the tissues, or by giving undue activity to the removal 
of that which already constitutes them, produces general emacia- 
tion. It is probable that both modes of action combine to produce 
the loss of flesh which attends nearly every acute disease, while 
the second is especially operative in cases of chronic structural 
disease, such as tubercle and cancer, which produce a gradual and 
progressive wasting, even while the appetite and digestion remain 
unimpaired. 

Local atrophy may be said, in general terms, to depend upon a 
diminished supply of blood. This is clearly the case when the tes- 
ticle shrinks after ligature of the spermatic artery for varicocele. 
That the same effect is not so distinctly seen in other organs, is 
owing to the anastomotic connexions of their vessels, through 
which they receive an adequate amount of nourishment, after the 
supply by the principal artery has been cut off. Inaction of a part 
disposes it to atrophy, just as its over-action inclines it to hyper- 
trophy. The ovaries of females past child-bearing become shrivel- 
led, as do also the testicles of old men. The thymus gland and 
the renal capsules are subject to the same law; their functions 



ATROPHY INDURATION SOFTENING. 445 

cease at birth, and they soon afterwards waste away. A limb long- 
kept at rest, undergoes partial atrophy, as may be constantly ob- 
served in the treatment of injuries of the extremities by surgical 
apparatus, which prevents or greatly restrains motion. Pressure 
also induces atrophy, as in the case just mentioned, and in those 
more numerous ones where an interstitial effusion of fibrin, or of* 
some pseudo-plastic matter, such as tubercle or cancer, compresses 
the adjacent structure, and suspends its functions. 

Induration is an abnormal increase in the consistence of an 
organ, and may exist under various circumstances. It may be 
owing merely to a deficiency of blood in a part, in consequence of 
which its denser particles are more closely aggregated, and there- 
fore offer an increased resistance. Such induration is never strongly 
marked. Hardening is most frequently a result of inflammation, 
and is then owing to the deposit and coagulation of fibrin in the 
affected organ. A familiar example is presented by pneumonia ; 
the hardening of the lung in this disease is called hepatization. 
Often, indeed, the grade of action accompanying this deposit can 
hardly be called inflammatory ; but the result is the same. Thus, 
in cirrhosis of the liver, the organ is at first enlarged by a fibrinous 
deposit, which gradually contracts and hardens, rendering the liver 
hard and tough, and reducing its size. The same thing occurs in 
Bright's disease of the kidney. Other varieties of interstitial deposit 
produce induration. There are other instances of this condition 
which cannot be well explained. The brain, for instance, is some- 
times unusually firm, almost as much so as if it had been coagu- 
lated by alcohol. 

Softening is the opposite of the change last described, and is 
often due to a cause the contrary of that first mentioned as pro- 
ducing induration, viz. : to a saturation of the tissues with fluid. 
General softening is seldom met with, except when the blood is de- 
prived of a portion of its fibrin, and is therefore more readily im- 
bibed. This is well illustrated by the state of the organs in typhus 
fever. Those of them especially, which, during life, were abun- 
dantly supplied with blood, show a greatly diminished consistence. 
The liver and spleen are frequently so soft that they will not bear, 
without rupture, the handling necessary to remove them from the 

38 



446 MORBID ANATOMY. 

body. The muscles are all flabby, and oftentimes the heart is un- 
able to retain its form when laid upon the table, and collapses like 
an empty bag. This form of softening is regarded by some mor- 
bid anatomists as a degree of general putrefaction commencing be- 
fore death. In some acute inflammations of the intestinal canal, 
its mucous membrane has so little tenacity as to look and feel like 
an unorganized pulp. The nervous centres, and particularly the 
brain, are very subject to softening. In the greater number of in- 
stances, this change is clearly inflammatory. In others, attended 
with chronic symptoms, it has been attributed to closure of the arte- 
ries supplying the affected part, by which a condition resembling 
gangrene is produced. But a full investigation of the subject has 
led to the conclusion, that chronic softening of the brain is pre- 
ceded by hyperemia, if not by inflammation, strictly so called; 
and that where obliteration of the arteries coincides with diminished 
consistence of the cerebral structure, it is the effect and not the 
cause of the process which results in softening. 

Another form of softening is that which takes place in interstitial 
deposits, whether fibrinous, tuberculous, or cancerous. Suppura- 
tion, as will be more fully shown hereafter, is of this sort. In all 
of the cases comprised in this division, induration precedes soften- 
ing. The deposit is formed within and around the elementary 
fibres of the tissues, and sooner or later, upon softening, carries 
away portions of the affected organs. In some cases, the soften- 
ing is supposed to depend immediately upon an interruption of the 
circulation, either by pressure upon the vessels, or by inflamma- 
tion of their lining membrane, and coagulation of the contained 
blood. 

Inflammatory gangrene is a form of softening. It is produced 
by extravasated blood, or other fluids, which pass rapidly into a 
state of decomposition, and become capable of destroying the vi- 
tality of the tissues which confine them, and thus produce their dis- j 
charge from the body. 

Transformation of tissues. — By this phrase is meant the conver- 
sion of one into another normal tissue. All of the tissues are not 
equally susceptible of transformation. Cellular or areolar tissue, 
which is the rudiment or basis of all the rest, may undergo every 



TRANSFORMATION OF TISSUES. 447 

known variety of this process. It is by the deposit of nutritive 
matter in this tissue, that all solutions of continuity are repaired, 
and all lost parts regenerated. But some tissues, it is believed, are 
never renewed in this manner ; such are the muscular, the nervous, 
and the glandular. On the other hand, osseous, adipose, and mu- 
cous transformations, are very frequent. The laws which regulate 
them are precisely the same as govern the original development of 
the tissues in the embryo ; as in the more complex transformations, 
the process advances through several successively higher grades, 
so in atrophy, or the degradation of compound organs, the same 
steps are descended, until nothing of the part is left but rudimen- 
tary areolar tissue. 

Cartilage, according to many writers, is deposited in the heart 
and arteries, and is sometimes transformed into perfectly organized 
bone. This statement is erroneous. The so-called ossification of 
the valves of the heart and of the arteries, consists in the deposit 
either of a gelatinous or amorphous semi-cartilaginous substance 
upon the internal surface of the vessels, or of calcareous matter 
between its coats. In neither case is true bone formed in these 
situations. 

The skin and mucous membrane appear to be convertible into 
one another. Whenever two cutaneous surfaces habitually rub 
against each other, they at length become soft, and secrete a fluid 
like mucus. This is of frequent occurrence in the groins and be- 
tween the buttocks of infants, and under the mamma? of very fat 
females. The mucous membrane of the vagina and rectum when 
prolapsed, and after long exposure to the air, assumes every cha- 
racter of true skin. 

The copious deposit of fat around atrophied organs, the heart for 
example, is usually cited as an instance of transformation. But 
here the original tissue is not transformed. It is removed, and its 
place supplied with adipose matter deposited in the meshes of the 
areolar tissue. 

Cellular tissue is frequently transformed into mucous membrane. 
All fistulous sores formed in this tissue acquire a mucous lining. 
The opposite sides of such fistulce, like those of all mucous canals, 
are very difficult to unite, so much so, indeed, as frequently to 



448 MORBID ANATOMY. 

render necessary the destruction of the lining membrane by means 
of caustic, or the knife, in order to produce their adhesion. 

Homologous tumours. — The alterations of nutrition hitherto con. 
sidered, affect the normal tissues, chiefly by causing the dimensions 
of the organs to increase or decrease, or by furnishing the means 
of repairing their injuries; they are not inconsistent with the pre- 
servation of the natural shape of the parts where they occur. But 
the proper organic constituents of the body may be developed in 
an abnormal form, constituting one of the two great classes of tu- 
mours. To the first of these classes, Vogel, (whom we shall 
mainly follow in the ensuing description,) refers all tumours whose 
anatomical elements agree with those of the normal body, and 
which, being once formed, discharge the duties of the normal con- 
stituents of the body, take a part in the general metamorphosis of 
tissue, and are nourished and increased like other parts. They 
are called homologous (ojuiojo?, resembling), from the resemblance 
of their constituents to the natural tissues, and also non-malignant, 
to distinguish them from tumours of the second class, whose ele- 
ments are essentially morbid, and which are called heterologous 
(£rS£o£, other) or malignant. This distinction is, nevertheless, in 
some degree artificial, since there are tumours which partake of the 
characters of the non-malignant as well as the malignant classes ; 
tumours, which in their origin, and for some time afterwards, con- 
tain only tissues analogous to the normal tissues of the body, but, 
subsequently, in consequence of mechanical injury or some unknown 
cause, have tubercle, cancer, or some other heterologous substance 
formed within them. 

The tissues of most frequent occurrence in non-malignant tu- 
mours, are the cellular, fibrous, muscular, adipose, vascular, 
cartilaginous, and osseous ; and, in the great majority of cases, 
two or more of these constituents are combined. They grow and 
are nourished precisely as natural parts, except that their increase 
is at times very rapid. This circumstance may be attributed to the 
irritation, and consequent hyperemia, produced by such tumours, 
in adjacent parts. Their elements are subject to all the transfor- 
mations which have been described. So long as they retain their 
original composition they constitute purely local forms of disease, 



HOMOLOGOUS TUMOURS. 449 

producing no reaction in the economy, and becoming prejudicial to 
health chiefly through their bulk, and their pressure upon import- 
ant organs. Their ordinary position exposes them to injury, and 
their low grade of vitality renders them peculiarly liable to destruc- 
tive inflammation from such causes. 

The following groups of homologous tumours are admitted by 
Vogel and other late pathological writers. 

Vascular tumours. — These are also known as erectile tumours, 
aneurisms by anastomosis, &c. They are of a red or bluish-red 
colour, of various forms and sizes, more or less firm, and more or 
less capable of temporary erection. They generally appear upon 
the skin, and in the subcutaneous cellular substance. They are 
often congenital, (hence the name of one variety of them, ncevus 
maternus), but may also arise at any period of life, without per- 
ceptible cause, or in consequence of mechanical injury. They 
consist of enlarged capillary vessels ; when arteries predominate, 
the tumours during life exhibit pulsation ; and when veins, they 
present a bluish colour. Vascular tumours which project above 
the surface of the skin, contain, in addition to enlarged vessels, 
areolar and fibrous tissue. 

Fatty tumours. — These tumours may be composed of fat alone, 
and they then receive the name of lipoma; or the areolar tissue 
enclosing the fatty particles may be well marked, or even fibrous, 
in which case a section of the mass resembles a slice of fat bacon. 
This form is denominated lardaceous (lardum, Lat.), and also 
steatoma (tf«rsag, suet). Sometimes fatty tumours are enveloped in 
a sheath of areolar tissue forming an imperfect cyst, and serving 
to connect them with surrounding parts. They are most frequently 
met with in the subcutaneous tissue of the back, but occasion- 
ally upon the face and extremities. They grow rapidly, and often 
attain a considerable size, weighing as much as twelve, or even 
twenty-five pounds. According to Vogel, many forms of malignant 
tumour — as encephaloid — have in their physical properties the 
greatest similarity to fatty tumours, and can only be distinguished 
from them by a microscopical examination. The grounds of this 
diagnosis will be subsequently pointed out. 

Fibrous tumours, — Tumours composed chiefly of fibrous tissue 
38* 



450 MORBID ANATOMY. 

are very frequent; they differ in their physical properties according 
to the stage of development of-this tissue, and its combination with 
other organic elements. Their simpler forms may be divided into 
three groups, the areolar, the fibrous, and the muscular, according 
to the predominance of these tissues respectively. They may also 
be classed with reference to their density. Those in which the 
fibres are most loosely connected, are called desmoid, from their 
resemblance to the structure of the skin. When more solid, firm, 
and elastic, and creaking or grating under the knife, they receive 
the name of sarcoma ; and when of a still harder texture, almost 
homogeneous, and of a milk-white colour internally, resembling 
cartilage, they are termed chondroid. 

The connexions of fibrous tumours are various. Many of them 
are, as it were, fused into the surrounding parts, and consist, in 
reality, of normal fibrous structure in a state of hypertrophy. 
Others are more or less isolated, and are occasionally as much 
detached from the surrounding structure as a kernel from its shell. 
This is remarkably the case when these tumours are seated in the 
uterus. When developed near either surface of this organ, they 
are apt to become pediculated, and, when they arise from its in- 
ternal face, may produce symptoms like those of threatened abor- 
tion, until the tumour escapes from the os uteri, where it may still 
be held by the toughness of its pedicle. On other occasions, the 
tumour ruptures the lining membrane of the womb, producing 
hemorrhage and violent expulsive pains. 

Most fibrous tumours contain vessels, but some appear to be 
nourished by deposits from adjacent parts. In some there is a 
considerable deposit of fat, and in others a partial transformation 
into cartilaginous tissue may be detected. The tumours under 
consideration occur in all parts of the body where fibrous tissue 
abounds; "upon the skin and mucous membrane, in the form of 
hypertrophy, condylomata, warts, and polypi ; on the muscular 
coat of the intestinal canal, in the muscular tissue of the uterus, 
and in the ovary ; in the cavities of the thorax and abdomen, 
where they often reach a very considerable size; and in the cavity 
of the skull, where they frequently arise from the dura mater." 
They produce disorganization in surrounding parts only by their 






HOMOLOGOUS TUMOURS. 451 

mechanical irritation. They often become transformed, wholly or 
partially, into calcareous concretions, improperly called ossifica- 
tions, and, like other homologous tumours, may be combined with 
malignant elements. Of their causes, nothing more is known than 
has been stated in regard to tumours generally. 

Cartilaginous Tumours. — Tumours composed chiefly of a tissue 
resembling cartilage are infrequent, except as connected with the 
regeneration or the abnormal growth of bones, as in callus and 
exostoses. In the latter cases, however, their existence is transi- 
tory, for they are ultimately converted into true bone. Echon- 
droma, as the form of tumours in question is called by Muller, has 
a closer resemblance to fibro-cartilage than to normal cartilage. 
It usually appears in the long bones of the hands and {"eet, "as a 
rounded, smooth tumour of variable size, enclosed in a bony case, 
which varies in thickness at different points, and in some is not 
unfrequently absent." This form arises from the interior of the 
bones. Another, which is formed upon their surface, chiefly of 
the flat bones, is covered only with periosteum, and has a less 
regularly rounded shape. Both of these forms contain osseous 
particles. A third variety, which contains no bone, is of less fre- 
quent occurrence, and has been met with only in glandular parts. 
It is of very slow growth, and therefore may attain a considerable 
size without seriously annoying the patient. 

Osseous Tumours. — True osseous tumours usually appear in or 
upon bones or fibrous membranes, and have all the anatomical and 
chemical characters which distinguish normal bone. Tumours 
which consist only in part of true osseous substance almost always 
arise from diseased bone, and usually contain fibrous tissue, ves- 
sels, cartilage, fluids enclosed in cysts, or even malignant elements 
as encephaloid or tubercle. Their mode of origin and tendencies 
present nothing peculiar. 

Melanotic Tumours. — Melanosis has generally been ranked 
amongst the heterologous products ; but the dark pigmentary mat- 
ter found in a great variety of situations, and to which this name 
has been applied, is now alleged to be a merely accidental consti- 
tuent of a great many different sorts of tumours. " This pigment," 
says Vogel, "is never the sole constituent of melanotic tumours; 



452 MORBID ANATOMY. 

it forms only a portion of the whole, and is scattered amongst 
other histological elements, such as perfectly-developed or compa- 
ratively amorphous fibrous tissue, vessels, (which, however, are 
never abundant,) and malignant formations, as tubercle, encepha- 
loid, and scirrhus." The colouring matter is not even identical in 
all the cases; it may consist of the peculiar melanotic pigment, or 
of the sulphuret of iron, or, finally, of altered blood-pigment. 
Hence it is evident that all which has been written concerning the 
habitudes of melanotic tumours, of their innocuous or malignant 
qualities, &c, has proceeded upon an erroneous assumption, and 
that the morbid relations of true melanosis are still to be settled. 

Gelatinous Tumours. — A viscid, gelatinous substance is some- 
times found infiltrated amongst the elementary tissues, or enclosed 
in appropriate cavities. Like melanosis, this substance may be 
associated with various normal or morbid elements, and like it, 
also, has generally been described as a variety of cancer, because 
it has been met with most frequently in conjunction with the essen- 
tial constituents of cancer, in that form called colloid, or glue-like 
cancer. Under this head it will be again referred to. 

Encysted Tumours. — It is characteristic of these tumours that 
they possess a perfectly closed membranous sac, whose contents 
are slightly or not at all organized, and show no organic connexion 
with the sac itself. They are divided by Vogel into two groups, 
of which the first embraces encysted tumours, with aqueous or 
serous contents, and the second those containing particles which 
render the fluid thick and pulpy. 

Serous encysted tumours occur in several forms. First, as a 
mere local effusion of serum into loose areolar tissue, or under a 
thin membrane, — in fact, a form of oedema. The membrane of 
the sac is not, in this case, a new structure, but consists of the 
normal structure, distended with fluid. Many examples of so- 
called hydatids, as of the spermatic cord and choroid plexus, those 
occurring beneath serous membranes, and a large proportion of 
tumours known as ovarian dropsy, are referrible to this form. A 
second form consists in the distention of a certain portion of the 
duct of a secreting organ, or of the organ itself by the retained 
secretion. In this manner are probably formed the transparent 



HOMOLOGOUS TUMOURS. 453 

vesicles so frequently met with upon the surface of the kidneys. 
The third form of the first group of encysted tumours resembles 
the first in its mode of development, but differs from it in possess- 
ing a more substantial eyst, which is lined by a thin, smooth epi- 
thelium, having the characters of a serous membrane. The 
greater thickness and denser substance of the walls of the cyst, as 
compared with the vesicular tumour, is supposed to depend upon 
the circumstance that the effused fluid is originally fibrinous, and 
deposits its coagulable element upon the internal face of the cyst- 
membrane ; the fibrin thus deposited becomes organized, grows, is 
susceptible of transformation into fibrous or other tissues, and is 
lined with an epithelium which secretes a purely serous fluid that 
contains no fibrin. This description applies to most cases of large 
encysted dropsy of the ovary. 

The second group of encysted tumours comprises all in which 
the contents of the cyst are not serous, but consist of substances 
resembling honey, gruel, jelly, or in part of still more solid ingre- 
dients. They have received various names, depending upon their 
accidental composition, such as hygroma, meliceris, atheroma, 
gummy tumour, &c. The walls of these cysts are much like those 
last described, but their internal membrane has a closer analogy 
with mucous than with serous tissue, sometimes presenting vegeta- 
tions, secernent follicles, and an epithelium, resembling perfectly 
that of the skin and mucous membranes. The thickness of the 
contents of the cyst often depends upon the accumulated debris of 
the epithelium, whose superficial scales are constantly thrown off, 
and cannot, of course, escape from the cyst. In most instances, 
however, some of the fatty constituents of the body are present, 
such as olein, margarin, the fat acids, and sometimes cholesterin. 
Their source is uncertain, but is supposed, in some instances, to be 
the sebaceous follicles of the lining membrane of the tumour. Fre- 
quently, the calcareous salts are deposited in considerable quantity, 
and the cyst, as well as its contents, becomes entirely, or in part, 
converted into a concretion. It is then, according to the common 
phraseology, said to be ossified, although it may contain no true 
bony substance. 

The most extraordinary circumstance connected with the en- 



454 MORBID ANATOMY. 

cysted tumours under consideration, is that they occasionally con- 
tain highly organized structures, as, for instance, hair, bone, teeth, 
and horny tissue. Hairs of various lengths and colours have been 
found in them, perfect in all their parts ; some growing from the 
lining membrane, and others loose within the cavity, which had 
doubtless been thrown off like the epithelial scales before mentioned. 
In a case recorded by Dr. J. B. S. Jackson, the lining membrane, 
from which the hairs grew, consisted apparently of well-formed 
cutis and cuticle.* The bone met with in these tumours generally 
lies between the layers of the walls, or in subordinate fibrous cells. 
They have the organization of normal bone, and are usually in- 
vested with periosteum. In form, size, and number, they present 
the utmost diversity. Perfectly formed teeth, resembling those 
either of the first or of the second dentition, are also met with ; 
like these, they possess a crown and root, and consist of osseous 
substance, dentine, and enamel. They may have the form of either 
of the normal varieties of the teeth, and are developed with pre- 
cisely the same succession of stages. They are sometimes few in 
number, (as from one to six,) sometimes more numerous, (as forty- 
four,) and in one case of ovarian tumour, recorded by Ploucquet 
and Autenrieth, there were no less than three hundred teeth, be- 
sides numerous misshapen bones. Whenever teeth and bones have 
been met with in tumours, hairs also have been found. The origin 
of these productions is wholly unknown. The opinion of Cruveil- 
hier and others, that they pertain to an undeveloped foetus, is no 
longer entertained ; and it can only be said that, as the cyst con- 
tains mucous, dermoid, and fibrous tissues, an apparatus exists 
capable of generating teeth, hair, and bone. But the cause of its 
peculiar action cannot even be conjectured. Horny substance, 

* " A Descriptive Catalogue of the Anatomical Museum of the Boston So- 
ciety for Medical Improvement, by J. B. S. Jackson, M. D., Curator of the 
Museum, Professor of Pathological Anatomy in Harvard University. Boston, 
1847." This is by far the most important and original illustration of morbid 
anatomy yet published in America. It bears equally strong testimony to the 
scientific zeal of the physicians of Boston, and to the earnest industry of the 
accomplished Curator, by whose exertions, chiefly, the Museum of the Society 
was formed. 



HOMOLOGOUS TUMOURS. 455 

having a spiral and pointed form, has been observed in some rare 
examples of encysted tumours. 

Simple encysted tumours, containing fat and epithelial cells, 
occur most frequently upon the head, face, and back, and in the 
ovaries. They are, in general, solitary, and vary from the size of 
a pea to that of a cocoa-nut; occasionally from four to sixteen have 
been met with upon the same person. Those containing hairs alone, 
have been found in various parts of the subcutaneous tissue, and 
particularly in the neighbourhood of hairy parts ; but teeth and bone 
have been observed in tumours of the ovaries alone. Although 
encysted tumours, of the kinds thus far described, are not malig- 
nant, they are very apt to return after extirpation, unless every 
particle of the cyst is removed. Whatever portion remains, is in- 
capable of uniting with adjacent parts, but goes on secreting, and 
thus reproduces the tumour. 

Encysted tumours are not always simple, but are often formed 
of a congeries of separate cysts, some of which may contain dif- 
ferent substances ; or they may be divided into a number of pouches 
or imperfect cysts, communicating freely with one another. 



CHAPTER IV. 



NEW FORMATIONS, 



The products to be described in the ensuing pages, differ from 
all of the normal constituents of the body. They include pus, tu- 
bercle, and the several forms of deposit commonly called malignant. 
One feature is common to them all : a tendency to softening, which 
induces a greater or less destruction of the tissues in which they 
are deposited. Another is to dissemination throughout the system, 
in consequence either of a morbid constitutional condition, or to 
the development of germs carried from the point originally affected. 
This is not so apparent in regard to pus as in the case of the other 
abnormal products, a particular condition of the system being re- 
quisite to produce purulent infection. 

Pus. — An important fact, which is generally overlooked, has 
been insisted upon by Vogel, to wit: that numerous distinct fluids 
are confounded under the general term of pus ; such, for instance, 
as softened tubercle and cancer, and a mixture of epithelial scales 
with mucus. " Normal pus forms a creamy, thick, opaque, and 
homogeneous fluid, containing no flocculent matter, depositing on 
standing a caseous, grumous precipitate, and communicating a soft 
and fatty feeling when rubbed between the fingers. It has a faint 
yellow, and sometimes a white and faintly-green tint, and developes, 
as long as it remains warm, a peculiar mawkish animal odour, 
which it loses on cooling. It is somewhat sweet and insipid, and 
has a specific gravity of 1030 — 1033. It consists essentially of two 
distinct parts, of very minute organized particles, the pus-corpuscles, 
and of a colourless aqueous fluid, in which the pus-corpuscles are 
suspended, as in an emulsion." The form of these corpuscles is 
in general spherical, but sometimes elongated, oval, or rugged, va- 
rying in diameter between the 200th and 300th of a line, and are 



pus. 457 

often studded with minute particles, of about the 1200th of a line 
in diameter. The corpuscles of genuine pus consist of a nucleus, 
cell-wall, and contents. They are specifically heavier than the 
fluid in which they swim, and will sink to the bottom of it when 
pus is allowed to stand in a tall narrow glass. This fluid is iden- 
tical with the serum of the blood. 

Pus, in common with all new formations as well as all the pro- 
ducts of normal nutrition, is formed from exuded fibrin. In this sub- 
stance, as has been observed in fresh wounds, minute granules first 
appear, around which, either singly or in groups, a cell-wall is 
developed. This process may be completed in three or four hours 
from the first appearance of the granules. Hence it will be per- 
ceived that pus is formed externally to the blood-vessels, and in no- 
wise out of the modified corpuscles of the blood, as was once 
believed. 

The only satisfactory manner of determining the purulent charac- 
ter of a fluid is by microscopical examination, which distinguishes the 
true pus-corpuscles, above described, from the epithelial scales so 
common in the secretions of inflamed mucous surfaces, as well as 
from blood-globules, and the elements of softened malignant forma- 
tions. It is true that in a given fluid there may be a few particles of 
which it may be difficult to say whether they are purulent or not; but 
as the qualities of the fluid depend upon its containing a much larger 
proportion of one ingredient than of any other, there can be no dif- 
ficulty in deciding upon the nature of any given specimen of fluid. 
As a general rule, pus tends to escape from the body. It is in- 
susceptible of any higher organization, and its presence cannot fail 
to be injurious. In what is called healthy suppuration, this fluid 
is poured out from a membrane communicating with the exterior, 
or forms an abscess which by pressure causes the absorption of the 
tissues lying between it and the surface, and then discharges its 
contents, after which the parts resume very nearly their original 
condition. In unhealthy suppuration, on the other hand, this pro- 
cess is attended with a positive loss of substance in the part where 
it occurs, being sometimes productive of ulceration, and sometimes 
of gangrene. A discharge of a thin reddish fluid, called ichor, 
sometimes takes place from gangrenous and ulcerated parts ; it 

39 



458 MORBID ANATOMY. 

has no analogy with pus either in its composition or its origin, It 
consists of the serum of the blood tinged with dissolved hsematin. 
Occasionally collections of pus disappear ; their serous portion, 
and then their corpuscles, after being disintegrated, are absorbed. 
The morbid heterologous products which remain to be noticed 
may be divided into two classes, the former comprising those which 
are less, and the latter those which are more, completely organized. 
In the former are included typhous, scrofulous, and tuberculous 
deposits, and in the latter the several varieties of cancer. Of these 
a concise description will now be given. 

Typhous deposits. — It is well known that in typhoid fever, the 
glands of Peyer, in the lower part of the ileum, become prominent 
and then ulcerate, and that, in the same disease, the corresponding 
mesenteric glands frequently become enlarged, and subsequently 
soften. These alterations have been traced to the deposit of a pecu- 
liar substance in the sub-mucous tissue on which the glands of the 
intestine rest, and in the parenchyma of those of the mesentery. 
The same matter has been met with in the spleen and lungs, and 
under the mucous membrane of the trachea. It consists of a lar- 
daceous substance of a yellowish or whitish colour, which gradually 
softens, and, involving the normal elements of the part in this pro- 
cess, causes their destruction. The substance in question is partly 
amorphous, and partly granular or composed of cells and their 
germinal nuclei, and cannot now be distinguished from the deposits 
which occur in scrofula and tuberculosis. 

Scrofulous deposits. — These, as was just remarked, appear to be 
physically and chemically identical with the matter of typhoid fever, 
but while the latter runs through its course in a few days or weeks, 
the former are developed slowly, and may remain almost station- 
ary for months, before being finally softened and discharged. 
Scrofulous matter is most commonly deposited in the lymphatic 
glands. Its general characters vary a good deal : sometimes it is 
dense and firm, sometimes lardaceous, and sometimes has the ap- 
pearance and consistence of new cheese. Instead of softening, it is 
sometimes replaced by a calcareous deposit. 

Tubercle. — This is by far the most frequent and interesting of 
the class of deposits under consideration. Its name, derived from 



HETEROLOGOUS DEPOSITS TUBERCLE. 459 

its occurring usually in small rounded masses, was originally ap- 
plied to all such masses, without reference to their composition. 
It occurs in two forms, one of which, from the shape and size of 
the deposit, received from Laennec the name of miliary tubercles, 
{milium^ millet), and from its colour that of gray granulations 
from M. Louis. These granulations are small, rounded bodies, 
quite firm under pressure, and generally varying in size from half 
a line to a quarter of an inch in diameter. This substance is, 
however, sometimes infiltrated into a tissue, as the pulmonary, 
solidifying portions of it completely. The second form consists of 
rounded, opaque, granular, and cheesy masses. Tubercle may 
also be formed on serous membranes, appearing as little pearly 
excrescences, or semi-transparent patches, or may be spread upon 
mucous surfaces as a homogeneous cheesy layer. 

The origin of tubercle is involved in doubt. It is not settled 
whether the fluid, first secreted, is simply the fibrin of the blood 
which afterwards undergoes changes resulting in the production of 
tubercle, or whether there is already formed in the blood a peculiar 
principle which on being deposited in the tissues, coagulates, and 
assumes at once the form of tubercle. 

Both of the forms of tubercle above described are regarded by 
some pathologists as original, while by others, and with better rea- 
son, it is held that the gray granulations constitute the primary 
form of the deposit. It would appear to result from the observa- 
tions which have been made by morbid anatomists, that in many 
cases, at least, the gray semi-transparent infiltration first takes 
place, and that in course of time small yellowish points appear dis- 
seminated through it, which gradually increase and coalesce so as 
to substitute the opaque cheesy matter for that which previously 
existed. However this may be, the tubercular matter is exuded 
so as to fill up the interstices of the tissues, and these latter are 
as closely and perfectly invested by it " as the stones of a wall by 
the mortar which has been applied between them." The effect of 
this arrangement is evidently to compress the enclosed fibres, and 
to cut off their supply of blood ; for the tubercle itself possesses no 
trace of vascularity. 

Sooner or later, softening of the tubercle usually takes place, 



460 MORBID ANATOMY. 

and the portions of tissue imbedded in the deposit are at the same 
time destroyed; the mingled detritus, forming a thick purulent- 
looking fluid, tends, like the pus of an abscess, towards the exte- 
rior of the body, where it is generally discharged, leaving behind 
a cavity lined with a secreting membrane. This cavity may re- 
main open, or it may gradually contract, its walls becoming semi- 
cartilaginous, and its opposite sides at last uniting so as to leave 
only a dense cicatrix in its place. More rarely the contents of the 
cavity are only in part evacuated, and what remains behind un- 
dergoes a transformation into a fatty substance resembling putty. 
Finally, (and this is most apt to occur when the tubercles are not 
abundant,) a calcareous deposit takes the place of the tubercular, 
converting the latter into a chalky mass, or one of stony hardness, 
which remains encysted in the tissue without further disturbing the 
health. 

The softening now described is a termination common to the 
least as well as to the most highly organized of heterologous pro- 
ducts ; but while, as will be shown, the latter implicate in their 
destruction the tissues which are in contact with them, the influ- 
ence of the former does not extend beyond its own original limits. 
Each tuberculous granule is deposited, in consequence of a consti- 
tutional vice, and being once formed, it is almost, if not quite, in- 
susceptible of increase; its mischievous influence is thenceforward 
chiefly dependent upon its softening. Hence the malignity of 
tubercle depends in a very large degree upon the extent to which 
it is deposited in the organs. 

Persons of all ages are subject to tubercular disease; but young 
children and old persons less than others. There is no organ or 
tissue in which tubercle has not been found, but its most ordinary 
seats are the lungs and glandular structures, especially the mucous 
follicles of the small intestines and of the larynx. Subsequently 
to the age of puberty, tubercles are rarely found in other organs 
without also being met with in the lungs. 

Cancer or Carcinoma. — The history of this, the most malig- 
nant of the heterologous deposits, is still involved in great ob- 
scurity. Morbid anatomists are by no means agreed what cha- 
racters distinguish cancerous tumours from those which we have 



CANCER. 461 

included in the class of homologous morbid growths, but the most 
recent investigations seem to demonstrate that the true distinction 
can be settled by microscopical examination alone. 

Cancerous tumours are not wholly composed of new elements. 
The greater part of their bulk is, in many instances, identical with 
that of non-malignant tumours, and even more, a particular tumour 
may, during a considerable period, be in all respects non-malignant, 
and yet eventually become truly cancerous. Cancerous tumours, 
then, may contain fibres, blood-vessels, &c. ; but these constitu- 
ents are not characteristic or essential ; they serve only as a ma- 
trix, or bed, in which is deposited and developed a new substance 
which has no analogue amongst the healthy tissues. This sub- 
stance is composed of cells of various forms and degrees of deve- 
lopment. The primary cells are described by Vogel as " nucleated 
and round, or oval; they vary from the 300th to the 100th of a 
line in diameter, entirely dissolve on the addition of the caustic 
alkalies, and disappear, with the exception of their nuclei, on the 
addition of acetic acid." Others, which are still more charac- 
teristic, are caudate, or ramifying; or contain a large number of 
nuclei, or perfect young cells; or have a very thick wall, exhibit- 
ing a double contour; or have granules scattered over their sur- 
face, &c. The occurrence of any one of these forms is not con- 
clusive of cancer, but only the presence of several varieties of 
them in the same specimen. 

These cells are believed to have the power of generating new 
cell?, and by this process a cancerous tumour grows. Besides the 
proof of their possessing this power, which is derived from their 
formation, that of direct experiment may be invoked. " Langen- 
beck succeeded in inducing secondary cancerous tumours in the 
lungs of a dog, by injecting into its blood-vessels fresh cancer-cells 
from a tumour while still warm, which had been removed two 
hours and a half previously from the humerus of a man." 

Cancer, like other heterologous products, tends to softening; 
and until this process is set up, the injury occasioned by the dis- 
ease is purely local, and consists in atrophy of the tissues, and 
other effects of pressure. On the occurrence of softening, how- 
ever, not only do the adjacent parts become inflamed, ulcerated, 

39* 



462 MORBID ANATOMY. 

and corroded by the ichorous discharge from the cancer, but this 
fluid may cause inflammation of the adjacent veins and lymphatics, 
or, being conveyed into the blood, give rise to that peculiar earthy 
colour of the skin, and to disturbances in the nutritive and nervous 
functions, which, taken together, constitute what is called the 
cancerous cachexia. Moreover, partly by the absorption of cancer 
cells, and partly through the influence of the constitutional dia- 
thesis, new tumours may arise in parts of the body more imme- 
diately connected by venous and lymphatic trunks with the original 
seat of the disease, or in organs more remotely situated. Accord- 
ing to the former mode of propagation, a single cell may, as Dr. 
Walshe remarks, be regarded as the possible embryo of an entire 
tumour. 

The diagnosis of cancer, founded on its anatomical characters, 
must, it is evident, be very difficult whenever the homologous con- 
stituents of the tumour compose almost its entire bulk. Under 
these circumstances, our only means of removing doubt is to 
ascertain whether or not cancer cells are present. After softening 
has taken place, these cells are numerous, and perfect enough to 
render their detection easy. But this is precisely the stage when 
the rougher physical characters of the tumour, its effects upon the 
health, &c, are usually sufficient, of themselves, to decide the 
question. It is, for the most part, during the intermediate period 
between its first formation and its maturity, that the microscopical 
examination of a tumour leads to really satisfactory results. At 
that time the assisted eye may detect the characteristic elements 
in a growth presenting all the general features of a simple fibrous, 
or other non-malignant tumour. 

Three species of cancer are admitted by Vogel, Dr. Walshe, and 
other late morbid anatomists of competent authority, to wit : ence- 
phaloid, scirrhus, and colloid. These terms have now taken the 
place of the nearly endless catalogue of names applied by different 
writers to merely accidental varieties of the forms enumerated. In 
the ensuing description we shall follow, in all essential points, and 
in regard to the first two species, the authors who have been men- 
tioned. 

Encepkaloid. — This name (from iyxs(pa\os, the brain ; and sTSos, 



ENCEPHALOID. 463 

resemblance) was applied to the fully developed examples of this 
species of cancer, from their close resemblance to the substance of 
the brain. It, however, possesses no characters in common with 
the cerebral tissue, except that of being a pulpy matter lodged in a 
reticulated membrane, the matter in question consisting merely in 
cancer-cells. In some cancerous tumours these cells predominate ; 
in others, the areolar or fibrous tissue which encloses them. The 
former constitute encephaloid ; the latter scirrhous tumours. 

In consequence of the extreme softness of encephaloid, it com- 
presses the tissues, amongst which it is deposited, less than hard 
cancer, even when, as sometimes happens, it is infiltrated amongst 
their elementary fibres. For a like reason, it is more readily orga- 
nized, and, indeed, may become so highly vascular as to seem com- 
posed of vessels with an interstitial deposit of cancerous matter. 
To this form, which is one of the most speedily fatal, the name of 
fungus hcematodes is applied. 

Encephaloid is of very rapid growth, and sometimes attains an 
enormous size. Tumours as large as the head of an adult, are by 
no means uncommon. " Berard observed an encephaloid tumour, 
in the thigh of a female, as large as the body of a full-grown man." 
This form of cancer may be met with in almost every organ or 
tissue of the body, and attacks, with equal frequency, both sexes 
and all ages. 

The colour of encephaloid tumours varies considerably ; their 
most ordinary hues being the white and ashen colours of the brain. 
In other cases, an abundant supply of vessels gives the tumour a 
pinkish hue, and when hemorrhage from them takes place, the 
blood effused into the substance of the tumour renders it red or 
brownish. The consistence of these tumours is equally various. 
Some of them, even before softening, are not firmer than an in- 
fant's brain, in which case slight pressure will force the cancerous 
matter out of the areolar tissue containing it ; others are as firm 
as, or somewhat firmer than, the healthy adult brain ; so that the 
cancerous matter, when pressed out partially, retains the form of 
the little compartments in which it was lodged. 

Encephaloid is most commonly deposited in the form of rounded 
masses, enclosed in an imperfect cyst, and these by their arrange- 



464 MORBID ANATOMY. 

merit in groups, often give to a tumour a botryoidal aspect. This 
arrangement is most frequently met with in the lungs, liver, and 
ovary. In other cases, the individual portions of the tumour are 
of a less regular shape, but being enclosed in fibrous partitions, 
cause it to resemble the pancreas. The infiltrated form of depo- 
sition is of less common occurrence than the tuberiform, at least 
originally ; the extension of encephaloid from its primary seat, on 
the other hand, nearly always takes place by infiltration, and in its 
progress destroys even the hardest tissues. 

When encephaloid attacks the subcutaneous cellular tissue, or 
in the progress of its development from more deeply seated parts, 
reaches the surface of the body, the skin becomes involved; it 
grows swollen, and of a dusky red colour, and its veins stand out 
like blue cords. By degrees the skin ulcerates, fungous and ex- 
tremely vascular vegetations sprout from the surface of the sore, 
bleeding upon the least irritation ; the morbid deposit softens and 
is discharged, carrying with it the normal tissues which surround 
it; wasting and hectic fever are established, and rapidly bring on 
a fatal termination. 

Scirrhus. — Tn this variety of cancer, which obtains its name 
from its hardness, (<fxi$6g, hard,) the fibrous tissue predominates, 
or that firm amorphous substance which is, in reality, imperfectly 
developed fibrous tissue. So far as this predominating element is 
concerned, scirrhous are identical with simple fibrous tumours; but 
combined with it are cancer-cells, to which alone the malignancy 
of the compound tumour is due. The mode of formation here 
pointed out explains the difficulty, so frequently presented, of deter- 
mining whether a particular tumour is encephaloid or scirrhus ; for 
in some portions of the same mass the fibrous structure may pre- 
vail, and in others the brain-like deposit. It equally explains the 
value of a diagnostic mark between fibrous and scirrhous tumours, 
proposed by Cruveilhier before the microscope had been successfuly 
applied to this subject. This anatomist found that, in true scirrhous 
tumours, a milky fluid exuded from a cut surface when squeezed, 
while in simple fibrous growths no such result ensued. • This can- 
cerous juice, as it has been called, was nothing more than the 
cancer-cells, or the softer constituent of scirrhus. 



SCIRRHUS. 465 

The nutritive process is far less active in scirrhus than in ence- 
phaloid. The former contains very few vessels ; indeed, some ob- 
servers have denied that it is vascular at all. Owing, no doubt, to 
its scanty supply of blood, its increase is slow, and it never reaches 
a considerable size. The largest tumours of this sort rarely ex- 
ceed three or four inches in diameter. The same imperfect nutri- 
tion retards the process of softening in scirrhus. It does not affect 
so large an extent, nor spread so rapidly to the adjacent tissues as 
encephaloid, and consequently does not so immediately endanger 
life. From the description given above, of the mode in which the 
constituents of scirrhous tumours are combined, it will be readily 
understood that when softening takes place in them, the breaking 
up and discharge of the cancer-cells leaves hollows of various sizes. 
From some of these a thin, turbid, brownish, and watery fluid es- 
capes, or can be expressed ; from others, a thick, whitish, opaque, 
and creamy fluid ; and from others, again, a pultaceous or cheesy 
substance, of a pale yellow, or dull white colour, is protruded ex- 
actly like the matter of sebaceous follicles, leaving minute cavities 
in the sites it had filled. In the further progress of softening, the 
fibrous element of scirrhous tumours becomes involved, the dis- 
charge becomes ichorous and corrodes the adjacent normal tissues, 
and life is finally destroyed, as in encephaloid cancer. Although 
so much smaller than encephaloid, scirrhous tumours are produc- 
tive of more mischief before the stage of softening arrives, by 
compressing the nerves, blood-vessels, and other important con- 
stituents of the organs in which they are seated. They may occur 
primarily in the bones, voluntary muscles, heart, liver, lungs, brain, 
penis, and indeed in nearly all the organs of the body ; but they 
present themselves with greatest frequency, and the most distinct 
features, in glandular structures, and especially in the mammary 
gland. This variety of cancer usually attacks persons beyond the 
middle period of life. 

Scirrhus may be deposited in the form of tumours, or be infil- 
trated in the normal tissues. The first is their most frequent form. 
Scirrhous tumours are usually rounded or oval, with a more or less 
nodulated surface. They are never enveloped with a true cyst. 
Infiltrated scirrhus is generally met with in the uterus and brain. 



466 MORBID ANATOMY. 

The section of a scirrhous tumour is sometimes of a bluish-white 
or milky colour, with a peculiar semi-transparent glossiness, espe- 
cially when the structure is most dense; when the cells are more 
numerous it is of a white or gray colour with a shade of yellow. 
Other appearances already described are met with during the 
stage of softening. 

Colloid. — Although, as was before stated, colloid is usually 
reckoned amongst the varieties of cancer, and in accordance with 
usage is here described, yet there are important differences between 
it and both scirrhus and encephaloid. In the first place, it does not 
present, under the microscope, any of those cells which are cha- 
racteristic of unquestionable cancer ; in the next place, it is by no 
means so general in its diffusion as the forms above described, and 
rarely, perhaps never, is disseminated from a primary deposit; 
thirdly, its mode of softening is entirely different from theirs; and, 
finally, it does not, like them, produce that vitiation of the system 
known as the cancerous diathesis. With these qualifications we 
present a summary of its most conspicuous characters. 

Colloid consists essentially of an areolar fibrous texture, with 
cells of irregular shape varying in size from half a line to half an 
inch in diameter, and containing within them a jelly-like substance 
of a yellowish or reddish colour, of a consistence between that of 
apple-juice and semi-concrete albumen. In simple colloid deposi- 
tions these qualities are uniform throughout the tumour, a point, in 
addition to those mentioned, in which it differs from scirrhus and 
encephaloid. 

This disease occasionally affects the uterus, mammae, and bones, 
and forms an accidental addition to compound cystoid, bony, and 
other non-malignant tumours; but its seat of predilection is the 
sub-mucous cellular tissue of the alimentary canal. Next to this, 
it is most frequently found in the omentum. Dr. Gross, of Louis- 
ville, describes a colloid tumour met by him in this situation which, 
in regard to size, is probably unique. " It extended from the pelvis 
to the liver and diaphragm, surrounded the colon and a part of the 
stomach, and concealed from view nearly the whole of the abdo- 
minal viscera. Its thickness was from two and a half to three 
inches ; in length it measured nearly one foot, and in breadth more 



COLLOID. 467 

than eight inches. Its weight was estimated at twenty-five 
pounds." 

In the stomach, colloid, like other heterologous deposits, usually 
affects the pyloric extremity, and is infiltrated in the sub-mucous 
tissue. Here, as in other parts of the alimentary canal, it forms a 
mechanical obstacle to the passage of food, and by inducing atrophy 
of the normal tissues, renders the coats of the organ softer, and 
liable to rupture. But it manifests no disposition to ulcerate, and 
neither gives rise to much pain, nor that degree of sallowness and 
emaciation produced by true carcinoma. 

Colloid may occur at any period of life, but is most frequently met 
with between the ages of thirty and fifty. It is often latent ; that 
is to say, it occasions no symptoms, so long as it does not interfere, 
by its bulk, with adjacent organs, or mechanically interrupt the 
function of that in which it is seated, 



CHAPTER V. 

MORBID PRODUCTS NOT INCLUDED IN THE PRECEDING 
CLASSIFICATION. 

There are two classes of products which from their intimate 
connexion with disease, either as its cause, or its effect, require a 
brief consideration in this place. A detailed description of them 
would be appropriate only in a treatise on special morbid anatomy, 
and the reader is referred to books on that subject for obtaining a 
more particular account of the manner in which they severally 
arise, and the specific derangements produced by them in the or- 
gans which they respectively affect. These products are concre- 
tions and parasites. 

Concretions. — Concretions are inorganic bodies of various forms, 
sizes, and composition, which may be met with in numerous situa- 
tions, but are especially frequent in hollow, and in glandular or- 
gans. They are sometimes described as foreign bodies, and in one 
sense correctly, for when formed, they act upon the tissues that 
surround them precisely as similar substances would do, if intro- 
duced from without ; in another sense they cannot be so considered, 
for they are remotely the results of vital processes. The blood 
and every other fluid of the economy contains certain inorganic 
elements ; these are very abundant in some of the secretions and 
excretions, particularly in bile and urine, and, under the influence 
of disease, their aggregate quantity as well as relative proportions, 
are greatly modified. At this point, however, vitality ceases to 
control them; once they have escaped from the vessels, they are 
subjected to exclusively chemical laws, and their reaction upon one 
another differs in no respect from what would take place among 
the same elements, in a similarly constituted fluid, at the same 
temperature, &c, and external to the body. 



CONCRETIONS. 469 

In health, every fluid containing inorganic elements is perfectly 
competent to their solution ; but in disease this faculty may be im- 
paired, and that in either one of several ways. The fluid, for in- 
stance, may be deprived of so large a portion of its water, as to be 
unable any longer to dissolve the chemical compounds contained in 
if, these latter are consequently precipitated, and form the basis of 
concretions. Or the soluble combinations in the fluid may, by the 
accidental presence of a new agent, or an excess of one which be- 
fore existed in an inconsiderable quantity, be decomposed, and new 
compounds formed which are insoluble, and therefore assume the 
form of concretions. Thus it is that soluble urate of ammonia may 
be decomposed by the presence of an acid in the urine, and uric 
acid thrown down, forming a variety of gravel ; or when oxalic 
acid is mixed with the urine, or any other fluid containing lime, it 
seizes upon this base, and forms with it an insoluble deposit. The 
formation of concretions by chemical decomposition prevails in the 
urinary apparatus ; that by an excessive secretion of inorganic 
elements, or by a deficiency of water in the secreted fluid, owing 
either to evaporation or endosmosis, appears to be more active in 
glandular structures. 

Inorganic concretions are generally crystalline, but occasionally 
amorphous, and, indeed, often pass through the latter before ac- 
quiring the former condition. The particles remaining in the sepa- 
rate state are termed sand or gravel, and when they occur in 
larger and fewer masses, calculi. Such masses, however, may be 
composed in either one of two modes : either by the mere aggre- 
gation of particles of sand or gravel through the medium of tena- 
cious mucus, or by the regular deposit of crystals around one of 
these particles or some other body, often one introduced from with- 
out, acting as a nucleus. The successive deposit of new matter 
upon the calculus, usually gives to it a laminated form. In certain 
cases, the lamina? are not all of the same composition, but formed 
of several substances; there may be two, for example, regularly 
alternating with one another from the centre to the surface of the 
stone. This is most distinctly seen in vesical calculi ; one of 
which, for instance, may be composed of alternating layers of uric 
acid and the phosphates, in a ease where, in order to correct the 

40 



470 MORBID ANATOMY. 

acid state of the urine, alkalies have been administered at intervals, 
but with the effect of inducing a phosphatic deposit, instead of 
merely neutralizing the urine. 

Concretions vary extremely in their appearance; sometimes they 
are smooth, and sometimes, from the deposit of large crystals, have 
a rough and angular surface. When single, and lying freely fn 
a cavity, they are generally round; but when numerous, and espe- 
cially if soft, they may assume very irregular figures. The gall- 
bladder is sometimes distended, and entirely filled with concretions, 
which have as infinite a variety of shapes as figs packed in a drum. 
In the bladder they are generally round ; in narrow canals, cylin- 
drical and solid, if produced from the contained fluid, and they form 
fragmentary or perfect sections of hollow cylinders when deposited 
in their walls, as in "ossification" of the arteries. In the kidney 
they are sometimes branched, displaying a perfect mould of the 
pelvis and cones of this organ. In other situations they form 
shapeless masses of extremely various size. 

The principal seats and components of concretions are the fol- 
lowing : — The urinary apparatus, in which they are composed 
chiefly of uric acid, the urate of ammonia, the urates and phos- 
phates of ammonia, lime, and magnesia, and the oxalate of 
lime. The salivary glands, ducts, and mouth, in the two for- 
mer of which they occur as roundish or oblong masses of a 
whitish colour, and in the last, as a deposit upon the teeth, 
called tarta 1 ' : their principal constituent is carbonate of lime. 
In the lactic mdl glands, the nostrils, the throat, the tonsils, and 
the bronchia, they are composed of calcareous salts. In the 
liver, cholesterin, bile-pigment, and carbonate of lime, are their 
chief constituents. Concretions found in the intestines are some- 
times derived from the liver, pancreas, or fauces, but are more 
commonly formed in the digestive tube. The composition of true 
intestinal concretions varies considerably. In some cases they 
consist merely of an aggregation of indigestible substances which 
had been swallowed, such as magnesia, the husks of oat- meal, 
wheaten bran, the stones and seeds of fruits, and the woody fibres 
of many vegetable substances. These are bound together into an 
impacted mass by mucus, or coagulated fibrin, and perhaps some 
calcareous salts. Others are composed almost entirely of the 



CONCRETIONS PARASITES. 471 

last-named materials, which are derived either from the food or 
from the secretions of the bowel. In the parenchyma of the 
organs, concretions present a great many varieties of composition. 
The most frequent are gouty concretions, and those which succeed 
tuberculous deposits. The former consist of urate of soda or urate 
of lime, and occur in the cellular tissue around the joints; the latter 
are not original, but arise from the transformation of tubercle into 
cretaceous salts, especially the phosphate and carbonate of lime. 

Parasites. — Certain independent organisms, both vegetable and 
animal, are found in the human body. The vegetable growths are 
all microscopic, and belong to the lowest orders of plants, the algce 
and fungi. They are never met with except upon cutaneous or 
mucous surfaces, nor while these surfaces remain healthy. Usu- 
ally, a secretion of fibrin or mucus, undergoing decomposition, 
forms the soil in which they grow. In some cases, they are be- 
lieved to be the media of contagion, as in that form of impetigo 
which affects the hair-bulbs of the scalp, and is called favus. This 
is the most important example of their connexion with disease. 

Animal parasites are very numerous. Many of them are infu- 
sorial ; many belong to the class of insects and mites, as fleas, 
lice, bugs, and the acari, of which the most important one is the 
itch-mite. A class of higher consequence comprises several sorts 
of worms. Those which infest the intestinal canal are extremely 
common, and are the oxyuris vermicular is, or thread-worm, 
which inhabits the rectum ; the trichocephalus dispar, or long 
thread-worm, which is found in the large intestine, and especially 
in the coecum ; the ascaris lumbricoides, or round-worm, whose 
ordinary residence is the small intestine ; and the tape-worm, or 
tcenia, which also affects the same part. The kidney is occasion- 
ally the seat of a round-worm, called the strongylus gigas, mea- 
suring from five inches to three feet in length, and from two to six 
lines in thickness. For a detailed account of these animals, of the 
trichina, the echinococcus, of acephalocysts, and numerous other 
parasites of still inferior interest, pathologically, the reader must 
consult special treatises. 

The diseases with which even large intestinal worms are con- 
nected, appear to be sometimes the cause and sometimes the effect 



472 MORBID ANATOMY. 

of the presence of these parasites. Very often they exist in con- 
siderable numbers without producing the least disturbance of the 
economy, but in other cases they are unquestionably the cause of 
much suffering and ill health. How far they are themselves the 
result of a morbid state of the organs in which they appear, is still 
an undecided question. 

The origin of parasites is extremely obscure, and has long been 
a mooted point among naturalists. It may not be inappropriate to 
present a summary of the opinions which are entertained respect- 
ing a subject of so much interest, but in doing so, we shall confine 
our remarks to the parasitic animals which inhabit the interior of 
the body, or entozoa. 

It is evident that these animals must originate in one of two 
ways ; that they must be derived directly or indirectly from 
without, or be created out of materials existing within, and fur- 
nished by, the body. No other supposition is possible. If an 
entozoon is in any manner derived from without, it must be 
admitted that this takes place either through the reception of 
the animal itself, or of its ova. If either opinion be assumed, 
it follows that the parent animal must exist somewhere exter- 
nal to the body. But the parasites in question have never, in 
any case whatever, been detected except within the organism. 
If it is objected that many of these animals are so minute that 
they might easily elude discovery in the elements around us, the 
argument fails when applied to the giant strongylus, the stout 
lumbricoid worm, and the tsenia measuring many yards in length. 
Besides, even admitting for a moment the possibility of the 
parasites which inhabit the intestine, and other mucous cavities, 
having once existed externally, the insuperable difficulty still re- 
mains of explaining the entrance of entozoa into shut cavities and 
parenchymatous structures, into the eye, or the muscles, for ex- 
ample, and their presence in the unborn child, and even in the 
bodies of larger entozoa of a different species. On the other hand, 
if it is maintained that the ova are alone received, it must still be 
shown that the ova exist external to the body, which has never 
been done. Nor would the admission of this explanation be suffi- 
cient ; for many of the entozoa are not propagated by eggs, but 



ORIGIN OF ENTOZOA. 473 

belong to the viviparous class, so that in regard to them the diffi- 
culty remains undiminished. But granting the existence of ova 
without, and their reception into the body, it is still impossible to 
explain the development from them of the animals found in the 
parenchyma, in the embryo, &c, without at the same time admit- 
ting that the ova are not only carried to these localities through the 
blood-vessels, but actually pass through the walls of the capillaries. 
Such an admission would be a physiological absurdity ; for the 
extreme vessels will allow of the passage of a single blood-globule, 
at a time, and no more, and will not permit any denser fluid than 
the plasma of the blood to permeate their walls, how then could 
they afford a passage in any manner to ova, the least of which is 
ten times as large as a blood-globule? 

If the hypothesis now presented is untenable, it only remains to 
adopt the alternative one, to wit, that entozoa are generated or 
created anew out of the materials or the products of the living or- 
ganism. It may be urged affirmatively, in support of this doctrine, 
that each organ possesses its own entozoa ; the kidney, a species 
different from those of the intestine, which are, again, unlike the 
parasites of the liver. Even more, the several parts of the same 
organ generate dissimilar animals. The small intestine produces 
the round and the tape worms, the large intestine the two species 
of thread worms. These facts seem to show that some extremely 
local concurrence of circumstances is essential to the production of 
the several entozoa. It may also be argued, and we think the ar- 
gument unanswerable, that if spermatic animalcules, which exist in 
the testicle, are there spontaneously generated, no violence is done 
to probability in supposing parasitic animals to be produced in the 
same manner. It will hardly be denied that spermatozoa are lite- 
rally evolved from the constituents of the semen. But it is objected 
to the doctrine of spontaneous generation that it is against analogy, 
which everywhere supports the famous dogma, omne vivum ex 
ovo. This objection is a mere begging of the question. The de- 
cision of the case in hand involves the truth of the theory just 
quoted, and as we believe, must be allowed to show that this theory 
is not absolutely universal in its application. Other facts, also, 
amongst which are the following, tend to invalidate it. Nothing 

40* 



474 MORBID ANATOMY. 

can be more certain than that all organized beings were, at some 
time or another, created ; geology proves that successive genera 
and species have been thus created, at long intervals apart ; and 
the history of disease renders it probable that one affection at least, 
syphilis, which is now propagated only by direct descent, ex ovo, 
as it were, is really of comparatively recent origin. 

In conclusion, after a review of the preceding outline of an ar- 
gument upon the generation of parasitic entozoa, we feel obliged to 
admit that the weight of facts and probabilities is wholly on the 
side of the doctrine of spontaneous generation ; at the same time, 
we cannot but look with interest to the results of future observation 
in this field, nor altogether suppress the hope that the simple law 
of nature, omne vivum ex ovo, may even yet be found to embrace 
the classes which now appear to form so striking an exception to its 
provisions. 



INDEX. 



A. 

Abdomen, integuments of, 250 ; pains in, 251 ; tumours of, diagnosis, 253. 

Acclimation, 70 — 72. 

^Etiology, 49—114. 

Age, a predisposing cause, 75; in prognosis, 207. 

Albumen, of the blood, in disease, 425; proportion of, in dropsical fluid, 433. 

Anatomy, morbid, as a science, of modern origin, 406; symptoms explained 
by lesions, 407 ; its influence in localizing disease, 409 ; in giving value 
to physical signs, ibid ; in improving therapeutics and prognosis, 410. 

Animal exhalations, infections, 97. 

Appetite, signs from the, 263. 

Arteries, signs from the ; the pulse, 339 ; mechanism of, 340 ; auscultation of 
the arteries, 348 ; mechanism of natural and morbid sounds, 349, 350 ; 
signs from, 351 — 356; of brain, sounds in, 356; uterine, 359. 

Atrophy, causes of, 444 ; general and local, ibid. 

Auscultation, origin of, 193; value of, 194; methods of using, 195; the 
stethoscope, 194; precautions, 196; of the heart, 322; of the arteries, 
348 ; of the brain, 356 ; of the gravid uterus, 359 ; of the lungs, 385 
mechanism of normal sounds in do., 386 ; loud respiration, 387 ; feeble, 
388; prolonged expiration, 389 ; harsh respiration, 390; bronchial, 391 
cavernous, 392; amphoric, 393; sibilant and sonorous rhonchi, 394 
crepitant rhonchus, 395; sub-crepitant, 396; gurgling, 397 ; vocal reso 
nance, 398; bronchophony, 399; aegophony, 400; pectoriloquy, 401 
varieties of cough, 402; metallic tinkling, ibid. ; pleural friction sound, 
403 ; laryngeal and tracheal sounds, 404. 

Auscultatory percussion, how practised ; its value, 197. 



B. 

Body, exterior of the, 217. 

Blood, in health and pregnancy, 421 ; in disease, 422; in plethora and anemia, 
423 ; its fibrin, 424 ; its albumen, 425 ; coagulation of, 426 ; foreign sub- 
stances in, 428 ; abnormal distribution of, 429. 



476 INDEX. 

c. 

Cammann, Dr., 197. 

Cancer, essential characters and tendencies of, 461 ; diagnosis, 462 ; varieties 

of, ibid. 
Carcinoma, vide Cancer. 

Cases, how to be recorded and generalized, 175. 

Causes, defined, 60 ; of disease, obscure, 61 ; classified, 62 ; general predis- 
posing, 64 ; special predisposing, 73 ; exciting, 88 ; specific, 94. 
Cephalalgia, 295. 
Chemical theory of disease, 151. 
Chemistry, its application to pathology, 199. 
Chest, form, capacity, and movements of, 249 ; mensuration of, 186; succus- 

sion of, 188; percussion of, 379 ; auscultation of, 385. 
Clark, Dr. 197. 

Climates, as causes of disease, 66 — 70. 
Cold, as a predisposing cause, 64 ; as an exciting cause, 83 ; coldness as a 

sign, 234. 
Colloid, 466. 
Colour, of the skin, 227. 
Coma, 311. 
Concretions, 468 ; modes of formation, and forms, 469 ; seats and composition, 

470. 
Congestion, passive and active, 429. 
Constipation, as a sign, 268. 
Constitution, a predisposing cause, 79. 
Constitution, medical, 105; affects prognosis, 211. 
Contagion, 100; distinct from infection, 101 ; modes of conveyance, 101 — 103; 

incubation of, 104 ; proofs of in epidemics, 111. 
Convalescence, 124 — 127. 
Convulsions, tonic, 304; clonic, 306. 
Cough, 370 ; ausculted, 401. 
Course of disease, 120; causes which modify it, 120 — 123; an element of 

prognosis, 204. 
Crises, 127; their reality, 128; forms, 129—132. 
Critical days, 132 ; the question of their existence, 133. 
Cyanosis, from asphyxia, obstruction of the pulmonary artery, &c, 227 — 228. 



Death, 137 ; fades hippocratica, 138; from old age, 138; by syncope, 139; 

by asphyxia, 140; by coma, 141. 
Defalcation, 267 
Deglutition, signs from, 261. 



INDEX. 477 

Delirium, 309. 

Deposits, typhous, scrofulous, and tuberculous, 458; cancerous, 460. 

Diagnosis, 162. 

Diarrhoea, signs from, 269. 

Diet, as a predisposing cause, 81. 

Disease, hypothetical ideas of, 52, 53 ; defined, 54 ; supposed seats of, 56, 57 ; 
nomenclature of, 58, 59 ; types, 114 ; duration, 116 ; stages, 118; theories 
of, 149 ; the hippocratic, 151 ; the chemical, ibid. ; doctrine of the vital- 
ists, 153; humoral pathology, 154; solidist doctrine, 155; eclecticism, 
156; diagnosis of, 162 ; feigned, 172. 

Diseases, acute and chronic, 117; course of, 120; terminations, 123; local, 
142; general, 144; uncertain seat of, 148; nosological arrangement of, 
159. 

Dissection in reference to morbid anatomy, 412 ; rules for conducting, 413. 

Dress, as a predisposing cause, 83. 

Dropsies, 432 ; fibrinous and serous, 433. 

Duration of diseases, 116; affecting prognosis, 205. 



E. 

Emaciation, 225. 

Emotion, mental, a cause of disease, 91. 

Encephaloid, 462. 

Endemic diseases, 106; distinguished from epidemics, ibid. ; examples, 107, 

Entozoa, hypotheses of their origin, 472. 

Epidemics, 106 — 113; causes, 108; influence on other diseases, 109; modes 
of extension, 110 ; proofs of contagion in, 112; prognosis in, 211. 

Eructation, 264. 

Examination of patients, 167 ; interrogation and inspection of, 168; tact, 169; 
table of points to be noted, 170 ; simple language to be used, 172 ; deli- 
cacy towards females, 173; cautions relative to other patients, 174; of 
dead bodies, 412. 

Exciting causes of disease, 88; special, 91 ; mechanical and chemical, 92. 

Expectoration, 372 ; mechanism of, 373. 

Eyes, signs from the, 243. 



F. 

Face, the hippocratic, 138, 242 ; signs from the, 240 ; colour of the, 241. 
Facts, recorded and remembered, contrasted, 37. 
Facts, generalization of, 41. 
Facts and theories contrasted, 27. 
Faeces, qualities of, as signs, 270 — 274. 



478 INDEX. 

Fatigue, a predisposing cause, 84. 
Feigned diseases, how to detect, 172. 
Fibrin, of the blood, in disease, 424. 
Fluctuation, how to produce, 180. 
Flux, 431. 

Formations, new, 456. 
Frick, Dr., on the blood, 424. 



G. 

General diseases, with local lesions, 145 ; division into general and local, some- 

what artificial, 147. 
Generalization of facts, 41. 

Generation, signs from the organs of, 274 ; of entozoa, 472. 
Genius for observation, 46. 
Globules of the blood, in disease, 423. 
Growths, morbid, vide Tumours. 



H. 

Habits of life, as predisposing causes, 81 ; relation to prognosis, 210. 

Heart, its position, 315 ; movements, 317; theories of do., 318; its impulse, 
cause of, 319 — 322; murmurs, mechanism of, 322; signs of heart dis- 
ease, 324 ; prominent pra3Cordium, ibid. ; impulse changed in position and 
force, 325 ; increased action, 326 ; sounds altered in place, ibid. ; in rhythm, 
328 : in tone, 329 ; endocardial murmurs, 330 ; semeiology of, 333 ; 
localization of murmurs, 334 ; summary of endocardial signs, 337 ; exo- 
cardial murmurs, friction sounds, 338 ; foetal, 361. 

Hemorrhage, 43. 

Heterologous products, 456. 

Hiccup, 370. 

Humoral pathology, 154. 

Hypertrophy, 441 ; physiological and morbid, 442 ; in the several tissues, 443. 



I. 

Idiosyncrasy, 80. 
Illusions and hallucinations, 298. 
Induration, 445. 

Infection, 95; causes modifying its power, 96; malaria, 98; distinct from 
contagion, 101. 



INDEX. 479 

Inflammation, its physical phenomena, 434 ; local effects of, 435 ; in various 
tissues, 435—440. 



J. 

Jaundice, its various forms and causes, 230, 231 ; coma in, 312. 



Laennec the inventor of auscultation, 193. 

Lesions, anatomical, a source of symptoms, 407 ; what to be searched for in 

dissection, 418. 
Local diseases, structural or functional, 143 ; none absolutely local, 144. 
Lungs, percussion in diseases of, 379 ; auscultation of, 385. 



M. 



Malaria, 98 ; its modus operandi, 99. 

Medical records, must be precise, 39. 

Medicine, why uncertain, 31. 

Menses, signs from the, 276. 

Mensuration of chest, abdomen, &c, 186. 

Metastases, 135; opinions respecting them, 136 ; are rarely salutary, 137. 

Microscope, utility of the, 198. 

Mind, disorders of the, 308. 

Morgagni, his account and explanation of cyanosis, 228. 

Mouth, signs from the, 256. 

Movements, as signs of disease, 221. 

Murmurs, cardiac, 322; arterial, 349 ; respiratory, 386, 

Muscular power, alterations of, 301. 



N. 

Neck, signs from the, 247. 

Nervous system, signs from the, 289. 

Nosology, general, 158; systems of Pinel and others, 160; all arrangements 

in a great degree artificial and temporary, 164. 
Numerical method, the, 42 — 46. 
Nutrition, altered, 440 ; theories of, 441. 



480 I N 1) E X. 

O. 

Observation, a genius for, 46. 

Observation and speculation, their proper spheres, 28 — 30. 
Observations, medical, must be recorded, 36. 

Observer, medical, qualifications of, 163 — 167; classical education, 163; the 
study of cases, 164, education of the senses, 165 ; moral qualities, 166. 



Pain, an exciting cause, 90 ; in the abdomen, 251 ; causes of pain, 291 ; in- 
fluences modifying, 292: varieties of, 293; degree, 294; cessation of, 
295 ; in the chest, 379. 

Paralysis, of the face, 240; of other parts, 302. 

Palpation, 179. 

Parasites, classes of, 471 ; origin of entozoa, 472. 

Pathology, general, defined, 49 ; its objects, 50; mode of treating, 51. 

Patients, examination of, 167. 

Pennock, Dr., his flexible stethoscope, 195 ; on the pulse in old age, 342. 

Percussion, 188; origin and theory of, 188, 189; mediate, 190; mode of per- 
forming, 191 ; in diseases of the lungs, 379; normal sounds of chest, 
380 ; morbid sounds, 381 ; resonance, 382 ; dulness, 383 ; metallic sound, 
384; estimate of percussion, ibid. 

Perspiration, 236; colour of, 237 ; critical sweats, 237 ; odour of perspiration, 
238. 

Physical methods of examination, 177; pressure, 178; palpation, 179; the 
touch, 181. 

Pleximeter, forms of the, the finger the best, 190. 

Poisons, 92. 

Precision in medical records necessary, 39. 

Predisposition to disease, hereditary, 73; affects prognosis, 209. 

Pregnancy, the blood in, 421. 

Priapism, as a sign, 271. 

Professions, as predisposing causes, 81. 

Prognosis, 200; its difficulties; founded on diagnosis, 201 ; elements of, 202; 
the mode of invasion ; particular symptoms, 203 ; regularity of course, 
204; duration, nature, and seat of the disease, 205 ; extent, complications, 
and treatment, 206; age of the patient, 207 ; sex, the puerperal state, and 
hereditary tendency, 209 ; strength, disposition, and habits, 210 ; the 
epidemic constitution, and social condition of the patient, 211. 

Pulse, signs from the, 339 ; mechanism of the, 340 ; physiological varieties, 
341 ; in disease, 344 ; varieties, 344—348. 

Pus, its physical characters, 456; origin, diagnosis, and tendencies, 457. 



INDEX. 481 

R. 

Records of medical observation necessary, 35, 36. 

Recovery, 123. 

Rectum, examination of the, 183. 

Respiration, varieties of, in disease, 364 ; dyspnoea, 367 ; vide Auscultation. 

Rhonchi, vide Auscultation. 



S. 

Saliva, signs from the, 26L 

Scirrhus, 464. 

Scrofulous deposits, 458. 

Seasons, as causes of disease, 65, 66. 

Seat of diseases, 142; of some uncertain, 148; affects prognosis, 205, 

Semeiology, 213 ; vide Signs. 

Senses, perversions of, 297 ; illusions, 298. 

Sensibility, general, 290 ; diminished, 299. 

Sex, a predisposing cause, 77 ; in prognosis, 209. 

Signs, distinguished from symptoms, 213 ; — from the exterior of the body, 217 ; 
attitude, 218; decubitus, 219 ; restlessness, tremor, size, 221 ; increase of 
size, general and local, 222, 223 ; emphysema, 224 ; loss of flesh, 225 ; 
paleness, cyanosis, 227 ; redness, jaundice, 229 ; purpura ; temperature 
of the body, 232 ; coldness, 234 ; heat, 235 ; varieties of, 236 ; perspiration, 
237 ; — from the head, face, and neck, 239; physiognomy of the sick, ibid ; 
spasms and palsy of the face, 240; colour, 241 ; facies hippocratica, 242; 
the eyes and their appendages, 243 ; the forehead, 245 ; the lips and 
lower jaw, 246 ; the hair and neck, 247 ;— from the exterior of the trunk, 
248 ; capacity and movements of the thorax, 249 ; abdomen, pains in, 
251; tumours of, 253; — from the digestive apparatus, 256; the 
mouth, 256; the tongue, 257; the saliva, 261; swallowing, ibid; the 
appetite, 263 ; nausea and eructation, 264 ; vomiting, 265 ; defecation, 
267 ; the feces, 270 ; — from the genito-urinary apparatus, 274 ; the male 
and female organs of generation, 275 ; the urine, 276 ; — from the ner- 
vous system; their obscurity, 289; sensibility, 290; the senses, 297; 
anaesthesia, 300 ; — from the organs of voluntary motion, 301 ; paralysis, 
302; convulsions, 304 ; disorders of the mind, 308; — from the circulatory 
apparatus, 314 ; position of the heart, 315 ; movements of do., 317 ; im- 
pulse of do., 319 ; sounds of do., 322; signs from, in disease, 324 ; abnor- 
mal murmurs, 330 ; semeiology of, 333 ; — from the arteries ; the pulse, 
339 ; auscultatory sounds, 348 ; the veins, 358 ; from the gravid uterus 
and foetal heart, 359 ; — from the respiratory apparatus, 364 ; rational 
signs of disease in, 364; respiration, 365; cough, 370; expectoration, 

41 



482 INDEX. 

372; sputa, 374; percussion, 379 ; auscultation, 385 ; of the respiration, 

386; the rhonchi, 394; the voice, 398; the cough, 401 ; pleural sounds, 

403 ; of the larynx and trachea, 404. 
Sleep, morbid, 311. 

Softening of the normal tissues, 446 ; of abnormal deposits, 457, 460, 464, &c. 
Spasm, 304; of the involuntary muscles, 307. 
Specific causes of disease, 94 ; infection, 95 ; contagion, 100. 
Speculation and observation, their proper spheres, 28 — 30. 
Sputa, their quantity, 374 ; form and consistence, 375 ; odour, colour, and 

composition, 376 ; signs derived from, 378. 
Stages of disease, 118. 

Stille, Dr. Moreton, his conclusions regarding cyanosis, 228. 
Strabismus, 244. 
Succussion, 188. 
Swallowing, signs from, 261. 
Sympathy, 86. 
Symptoms distinguished from signs, 213 ; divisions of, 214. 



T. 



Tact, a faculty liable to abuse, 169. 

Taste, morbid, 258. 

Temperament, a predisposing cause, 78. 

Temperature, as a cause of disease, 64. 

Terminations of disease, 123; recovery, ibid ; convalescence, 124; crises, 127; 

metastases, 135 ; death, 137. 
Theories and facts contrasted, 27. 

Tissues, changes in the normal, 440 ; transformation of, 446. 
The touch, 181 ; vaginal, 182 ; rectal, 183. 
Tongue, signs from the, 257. 
Transformation of tissues, 446. 
Trembling, 303. 

Truth, its definitions and forms, 25, 26. 

Tubercle, 458 ; description of, and origin, 459 ; terminations, 460. 
Tumours of abdomen, 253 ; homologous, 448 ; heterologous, vide Cancer ; 

vascular, fatty, and fibrous, 449 ; cartilaginous, osseous, and melanotic, 

451 ; gelatinous and encysted, 452. 
Type of disease, 114. 
Typhous deposits, 458. 



U. 

Uncertainty of medicine, causes of the, 31 — 33. 



INDEX. 483 

Urine, characters of healthy, 277 ; physical do. of morbid, 279 ; chemical 
properties of morbid, 281 ; mode of examining-, 283 ; manner of voiding-, 
semeiology of the, 285—288. 



V. 



Vagina, examination of, 182 ; signs from the, 275. 

Veins, signs from the ; pulsation of the, 358 ; distension of the, 359. 

Voice, 398. 

Vomiting, 265 ; matters vomited, 266. 



W. 



Woillez, on the size of the chest, 248. 
Worms, vide Parasites. 



THE END. 



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Franklin Medical College, Philadelphia, &c. 

MINOR SURGERY. 

BY EDWARD HARTSHORNE, M. D. 

Lecturer on Legal Medicine in the Philadelphia Medical Association. 

GENERAL, OR MICROSCOPIC ANATOMY, 

BY FRANCIS G. SMITH, M. D. 

Lecturer on Physiology in the Philadelphia Medical Association. 

SPECIAL ANATOMY. 

BY JOHN NEILL, M. D. 

Lecturer on Anatomy, and Demonstrator in the University of Pennsylvania. 

PHYSIOLOGY. 

BY FRANCIS G. SMITH, M. D. 

Lecturer on Physiology in the Philadelphia Medical Association. 

MEDICAL CHEMISTRY. 

BY ROBERT BRIDGES, M. D. 

Professor of Chemistry in the Philadelphia College of Pharmacy, &c. &c. 

MATERIA MEDICA, AND THERAPEUTICS. 

BY FRANCIS WEST, M. D. 

Lecturer on Materia Medica and Therapeutics in the Philadelphia Medical Asso- 
ciation. 

CLINICAL SURGERY. 

BY EDWARD HARTSHORNE, M. D. 

Lecturer on Legal Medicine in the Philadelphia Medical Association. 

THE AMERICAN DISSECTOR. 

PREPARED ON A NEW PLAN 

BY J. M. ALLEN, M. D. 

Demonstrator of Anatomy, &c. &c. 

The series of Books now announced, will form a convenient and cheap Library o 

reference for the Medical Practitioner, or a complete set of Text Books for the Medical 

Student. Other works on the collateral Branches of Medicine will be announced from 

time to time, as they present themselves. 

TERMS OF PUBLICATION. 

Price for a Single volume, done up in a suitable form for mailing, $1 25 ; or for five 
volumes, $5 ; if paid for in advance. Persons at a distance can have the whole or anj 
part of the series forwarded to them by Mail, at Periodical Postage, upon remitting the 
amount to the Publishers, or sample volumes upon the remittance of One Dollar. 

LINDSAY & BLAKISTON, Publishers. 
Northwest Corner of Fourth and Chestnut Streets, Philadelphia. 



MENDENHALL'S MEDICAL STUDENT'S VADE MECUM. 

The Second Edition, Revised and Greatly Enlarged. 



LINDSAY AND BLAKISTON 

PUBLISH 

Ml SaiMIM' SttllDiHtt'S MIDI 11®I1 9 

OR 

MANUAL OF EXAMINATIONS 



ANATOMY, 
PHYSIOLOGY, 
CHEMISTRY, 
SURGERY, 

MATERIA MEDICA AND 
PHARMACY, 



PRACTICE OF MEDICINE, 
OBSTETRICS, 
DISEASES OF THE SKIN, 
AND POISONS. 



Second Edition, Revised and Greatly Enlarged, 

BY 

GEORGE MENDENHALL, M. D., 

ecturer on Physiology in the Medical Institute of Cincinnati, Member of the Philadelphia 
Medical Society, &c. &c. 

A NEAT POCKET VOLUME. 



Extract from the Preface to the Second Edition, 
The favourable manner in which the first edition of this book has 
3en received, and the rapidity with which it has been disposed of, 
mder it necessary to issue a second edition ; which has been revised 
id improved with great care, so as to bring it up to the present ad- 
mced state of the Science of Medicine. About one hundred and fifty 
iges of matter have been added that will be found to enhance its 
ilue materially; as some subjects entirely omitted in the previous 
lition have been supplied in the present ; and others have been ren- 
jred more full. 

! The object is to furnish the Student of Medicine with a short and 

iccinct view of the most important facts and principles which engage 

,.(; attention during his pupilage, in order that he may refresh, and fix 

)re firmly upon his memory what he has read and heard; as well as 

enable him properly to arrange his knowledge so as to use it in the 

>st advantageous manner. 



BANKING'S HALF-YEARLY ABSTRACT 

OF THE 

MEDICAL SCIENCES. 



No. 6, now ready, gives a complete accouut of the Uses of* Chloroform with an En 
graving of a. cheap and efficient Inhaler. 

OPINIONS OF THE PRESS. 

The foregoing is the title of a Medical Periodical, than which we know of none more 
suitable for the country physician who desires to keep pace with ihe improvements in his 
profession, but whose time is too much occupied, or whose means are too limited, to enable 
him to read, or purchase the numerous Medical publications containing the discoveries and 
improvements, constantly occurring, both at home and abroad. To all such, "Rankings 
Half-Yearly Abstract" would prove " a treasure of knowledge," as it contains all that is 
truly valuable, in a condensed form, of sixteen British, fifteen French, nine German, and 
seven American Medical Periodicals, served up, twice a year, in a closely printed volume of 
three hundred and sixty-four pages, at the astonishingly low price of a dollar and a half per 
annum. 

But it is not to those alone whose leisure and means are limited, that the "Abstract' 
would prove a valuable acquisition. Its pages are a vast store-house of information, from 
which all — from the grave and venerable practitioner, to the young physician just entering 
on his sphere of usefulness — may profitably procure much that is truly interesting and in- 
structive. — South Western Medical Advocate. 

The character of " Ranking's Abstract" is familiar to all. It is intended to preserve 
and present in a condensed form, all that is most valuable in the periodical and curren' 
medical literature of the day. The design is well conceived and ably carried out, and there 
is no other source within our knowledge whence such a variety and amount of choice 
matter can be obtained. 

Messrs. Lindsay and Blakiston are entitled to all praise for the very prompt manner ii 
which they issue each successive number, and for affording to the American physician— foi 
the trifling expense of one dollar and a half a year, — such a desideratum in medical litera 
ture.— St. Louis Medical and Surgical Journal. 

This deservedly popular work fully sustains its former reputation in this number. It is a 
full and interesting abstract of what is new in the different departments of our science. 

As a work of reference it is exceedingly convenient and valuable on account of th 
admirable arrangements of its contents, and the clear and full accounts given of the man 
improvements and discoveries which are being made during each succeeding six monihs- 
lllinois and Indiana Medical and Surgical Journal. 

The present No. of this valuable periodical fully sustains the high character of its preile 
cessors. The practitioner is here presented with almost every important fact connected will 
the current medical literature, and that, too, without the labour of wading through inni 
merable journals, and almost interminable details of cases. The low price at which it i 
published, should insure it a place in every medical library. — Western Lancet. 

This is a most valuable periodical to every practitioner of Medicine. It comprises ever) 
thing new and practical in a nut-shell as it were, in the whole circle of medical sciences 
We recommend it in the strongest manner to our readers. — Mobile Medkal and Surgica 
Journal- 

We wish once more to call the attention of our readers to this most excellent and compi 
hensive epitome of the current medical science of the day. It presents in a cheap and coi 
densed form the most valuable and practical results arrived at by the most learned men o 
the profession, and that, at so cheap a rate, as to be within the reach of every one. It car 
no longer be regarded as a luxury, but one of the necessaries to the medical man, wilhoU 
which he is very certain to remain ignorant of many new remedies and modes of treatment 
of which he cannot well be deprived. — New York Journal of Medicine. 

A more valuable periodical is not published. — Southern Journal of Medicine an\ 
Pharmacy. 

Teims SI 50 per annum. 75 cents per number, or $2 25 for the bound volumes, eachcwi 
taming one year of the work. Back numbers furnished. 

LINDSAY AND BLAKISTON, Publishers. 
O V" Philadelphia- 



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